Why Is Heart Failure Rehabilitation Important?
Heart failure is a serious condition. More than two-thirds of individuals with moderate to severe systolic dysfunction are hospitalized yearly and one out of three die within one year after hospi- talization. The heart failure group consumes >2%
of the total healthcare costs and the main costs are due to hospitalizations.1,2
There are several issues in the management and rehabilitation of patients with heart failure that need to be taken into account in order to improve outcomes. Many patients are not adequately diagnosed3 and do not have optimal treatment according to guidelines.4Patients hospitalized due to heart failure often have a short length of stay in the hospital and discharge planning and rehabili- tation are often not provided, especially not to the majority of heart failure patients who are above the age of 65 years. Education for patients with heart failure in order to teach self-care is often insufficient.5Patients’ satisfaction with care is sometimes low and patients ask for more support and education.6 It has been shown that non-compliance with medication, diet or symptom monitoring caused up to 50% of hospital readmissions.7
The Contribution of Nurses in Heart Failure Rehabilitation
Nurses are increasingly involved in heart failure care, especially in patient education, follow-up, and drug titration. During the later part of the
1980s, the concept of heart failure clinics often run by nurses was initiated in the US. In 1995, the first randomized study evaluating a nurse-based, multidisciplinary intervention that combined telephone follow-up and home-based visits was published. The results of this study showed that a nurse-based intervention could decrease hospital admission and improve quality of life and these findings started a boom in nurse-led heart failure programs and randomized trials evaluating these initiatives.
Sweden was the first country in Europe to estab- lish nurse-based heart failure clinics for patient education and follow-up and there are today heart failure clinics in 80% of the Swedish hospi- tals. There are now also heart failure clinics in more that one-third of the hospitals or more in Norway, Denmark, Iceland, the Netherlands, the United Kingdom, Greece, and Slovenia.8 Several other European countries are rapidly developing heart failure programs. In the US, Australia, and New Zealand heart failure programs are also common, but there are few reports from Asia and Africa about nurse-based initiatives in heart failure care.
Some nurse-based heart failure programs are home-based, some are clinic-based or a combina- tion of the two models. The majority also provide patient- or nurse-initiated telephone consulta- tions. Specially educated heart failure nurses staff the programs and provide discharge planning, structured follow-up and patient education, both pre- and post-discharge. The nurses can be dele- gated the responsibility for making protocol-led changes in medications, such as uptitrating ACE inhibitors, beta-blockers, angiotensin- and aldosterone-receptor blockers as well as spirono-
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Heart Failure Rehabilitation: The Role of the Nurse
Anna Strömberg
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lactone, terminating treatment with interacting drugs, and decreasing or increasing the daily doses of diuretics. A cardiologist retains medical responsibility and initiates or confirms the medical changes.
The focus of the majority of these programs is to monitor symptoms, optimize treatment, and provide patient education and support in order to increase self-care behavior. Despite the many positive effects of exercise training in heart failure, this component is seldom included for all patients in the heart failure programs. In this area there is room for improvement.
Telemonitoring is a tool that allows the heart failure team to monitor daily the physiological variables and symptoms measured by patients or caregivers at home. Patients with heart failure can be kept under close supervision in their own homes. Telemonitoring uses the technology of special telecare devices and a telecommunication system standard telephone lines, cable network or broadband technology. The use of telemonitoring has increased in order to support chronically ill patients. Before telemonitoring can spread broadly in clinical practice, more widely available low-cost, user-friendly telemonitoring equipment as well as further evaluations of effects are needed.
In telemedicine blood pressure, pulse or ECG, saturation devices as well electronic scales, symptom response system and video consultation equipment can be installed in the patient’s home.
The collected data are sent to a server usually in a hospital setting. A nurse monitors the vital signs
daily in order to detect changes suggesting dete- rioration of heart failure, and contacts the patient if signs of deterioration or no data occurs. The nurse reacts and takes action either on their own judgement or action algorithms or contacts the responsible physician when deterioration occurs.
Compliance with monitoring has been good and technical failures quite low, so it seems to be a fea- sible and reliable model of care.9 In Table 37-1, the advantages and disadvantages of follow-up through clinic visits, home visits, or telemonitor- ing are outlined.
Starting a Nurse-Based Heart Failure Rehabilitation Program
Goals and Key Components
Overall goals of the program should include both the patient and healthcare perspective.
Examples of goals on the healthcare level are to improve follow-up after hospitalization, im- prove quality of life and survival in patients with heart failure, reduce the number of hospital readmissions, provide evidence-based medicine and care regarding diagnostics, treatment, educa- tion and support, and perform regular quality assurance and audits of the program. Goals on the patient level can be to provide individualized patient education and increase self-care manage- ment and adaptation of living with chronic heart failure.
TABLE37-1. Advantages and disadvantages with different models of nurse-based heart failure programs
Advantages Disadvantages
Clinic visits Convenient to be in a hospital setting with Fewer patients are suitable for this follow up. Transportation to the medical facilities and equipment available hospital can be tiring for the patient and needs organization of Physician easily reached if nurses need a second transport and support
opinion or changes in medications or prescriptions
Home care The patients do not need to be mobile Time-consuming for nurses to travel to the patients Easier to assess the patients’ needs, Cars and mobile equipment are needed
capabilities and adherence to treatment Nurses alone with the responsibility.
in their own environment Difficult to reach the medically responsible physician Convenient to do a follow-up visit shortly
after hospitalization in the home
Telemonitoring Increasing need for this type of Steep learning curve to use the equipment, for patient and/or caregiver monitoring when more advanced care and healthcare providers
moving into the patients’ homes Unclear which variables are the most helpful to monitor New equipment is continually under development
The aim of nurse-based programs is to provide holistic, individualized, and evidence-based care.
The key components are: a diagnosis verified by echocardiography, rehabilitation provided by a multidisciplinary team with the objectives to provide optimized drug therapy, patient educa- tion and counseling with special emphasis on self- care, as well as psychosocial support to patients and family. The rehabilitation is started with early follow-up after hospitalization with the focus on high-risk patients, and is either home or clinic based with increased access to healthcare through telephone consultation and long consultations (30–60 minutes).
It has been debated which of the components in the nurse-based heart failure follow-up is the most important and effective, but apart from education, which has shown isolated positive effects,10,11none of the present studies have been designed to answer this question. However, it might be more relevant to consider this type of follow-up as a concept of care composed of several components with synergism instead of believing that just one single component could be enough to improve outcomes such as survival, morbidity, and quality of life.
Economic and Organizational Frameworks
The most important aspect in terms of economic and organizational issues is to set up a heart failure program that is adapted to the means and organization of the local hospital or primary care setting. The economic resources influence how the service can be organized, for example the number of nurses, physicians, and other healthcare professionals that can be appointed, what facilities that can be afforded, and the type of follow-up. In some cases new recourses are provided from the start, in other cases the program is paid by relocating budgets. The goal is cost-effectiveness. Another important issue is whether it is most convenient for patients and the staff to provide hospital-based clinic visits or home visits. If the visits are be hospital- based, well-functioning premises are demanded.
If it is home-based, transportation and mobile equipment are needed.
The timing of the first visit is still a matter of debate. Early follow-up after discharge is effective;
it should be done within the first days or weeks after discharge. The number of visits and length of the program are also under debate. Recent data have shown that only the first 3 months of follow-up reduce readmissions, so a longer follow-up might not be needed in stable patients.12 There is also evidence that the number of visits can be few and individualized according to the patient’s needs and that stable, optimally treated and well-informed patients can be referred back to their family doctor, often a GP or cardiologist.13
Create Relations Throughout the Chain of Care
Establishing a well-functioning collaboration throughout the whole chain of care, especially between primary and secondary care, is impor- tant. Good relations ensure that the competence and potential of the nurse-based program is used in the best way. It is relevant to elucidate the refer- ral of patients to the program and the type of service that can be provided. The responsibility for the total care and follow-up of stable heart failure patients must be defined in order to use human and material resources effectively; for example, the issue of discharge from the program or the need for readmission.
The patients need to be optimally diagnosed, treated, and educated according to guidelines irrespective of the caregiver. Therefore educa- tional initiatives are needed for all caregivers in the chain of care, as are regular contact channels.
Choose the Patient Population
Before setting up a program it is important for planning purposes to have knowledge about patient needs. Patients with heart failure are a heterogeneous group covering a large age span, with differences in etiology, severity of heart failure, and social situation. The majority of the patients are over 70 years of age and have several other co-morbidities such as diabetes, arthritis, cancer, chronic obstructive lung disease, or kidney failure.
The number of patients hospitalized each year due to heart failure and the percentage that are
suitable for follow-up need to be estimated as well as the number of patients that will be referred from other caregivers, for example primary healthcare. It is crucial to discuss which patients benefit the most from participating in the program.
Define the Content of the Program
The content of a follow-up visit or telephone call depends on how far a patient has reached in the course of the disease. It is important that optimal treatment according to guidelines and patient education are given directly after the diagnosis. A heart failure management program has a role in the uptitration of drugs such as ACE inhibitors, beta-blockers, angiotensin- and aldosterone- receptor blockers. Since most heart failure nurses do not prescribe drugs, titration protocols, delegations and treatment algorithms are needed as well as routines for prescriptions and consultations.
The first education session should include a definition of heart failure, rationale for and importance of following the prescribed pharma- cological and non-pharmacological treatment, as well as what self-care behaviors need to be per- formed such as symptom monitoring, physical exercise, lifestyle changes, and immunization.4
The information about the diagnosis can trigger a crisis for both patients and families due to the feeling that their life might be threatened.14 Support during the first session in order to adapt to the new situation of living with chronic illness might therefore be needed. One should emphasize that the goal of treatment and self-care is to live with as little limitation as possible in daily life. However, it is important to inform patients that they will not be cured, since many patients during periods of clinical stability feel that the do not suffer from heart failure anymore and might stop taking their medication or observe symptoms.
Patients with heart failure who have been hos- pitalized are considered as high-risk patients with a poor prognosis and at risk for readmission. The aim of an early outpatient visit is to assess the physiological status in order to detect signs of deterioration, optimize treatment, and discuss side-effects. Furthermore, educational needs
should be assessed and additional education pro- vided. Patients should learn to manage symptom monitoring and flexible intake of diuretics when signs and symptoms of fluid retention occur. After a period of deterioration, patients and families may experience insecurity and anxiety and need support. Consultations in nurse-based programs are often longer (30–60 minutes) than visits to the physician and enables a caring assessment, in-depth education and psychosocial support.
In order to prevent readmission the cause of the previous admission should be determined and addressed in order to lower the risk for readmissions.
Easy access to care through daily telephone hours facilitates the opportunity to discuss, symp- toms, treatment, and self-care behavior with a spe- cialized nurse.
Each program needs documentation. Key parts are the physiological status, sign of heart failure, health and life situation, treatment changes, the education and psychosocial support provided, and the plan for further follow-up.
Recruit and Educate Staff
Defining the amount of staff, the roles and responsibilities for the team members, and what additional education and training they need is important. Is the program mainly run by nurses with medical back-up from a cardiologist or should a multidisciplinary team be involved that will be coordinated by nurses? Often, team members have long experience of cardiac care in combination with a personal interest in heart failure care and additional education within heart failure care and treatment. Since many nurses have extended responsibilities in regard to inter- preting laboratory tests and echocardiography, assessing physiological status such as lung aus- cultation, symptom monitoring and titrating drugs for legal reasons, a written description of these tasks that goes beyond the nursing curricu- lum might be needed. In the US, many heart failure nurses are clinical nurse specialists or advanced nurse practitioners. Several nurses have master degrees. In Europe, nurses working in heart failure clinics often have quite long experi- ence (>5 years) of cardiac care in combination with additional education in heart failure. In
Sweden and Scotland there are university courses at degree level in heart failure care. In several other European countries there are shorter courses on how to set up and run a heart failure program.15
The Role and Responsibilities of the Nurse
A central issue to explore is the role and respon- sibility of nurses in heart failure programs.
Among all tasks, nurses have formal competence for some, delegated responsibility for others, while some extended tasks need additional training and education. There are huge differences both within and between countries regarding the education and competencies of registered nurses. There are legal differences as to what nurses are allowed to do within their license. The whole team needs to agree on the nurse’s tasks, responsibilities, and competencies. The job description needs to be clear and in agreement with formal and real com- petence. Networks for heart failure nurses are important in the further development of the role of nurses as well as the improved possibilities to influence policy makers and stakeholders in healthcare systems. Such networks now exist both in Europe through the Heart Failure Association within the European Society of Cardiology and in the US through the American Association of Heart Failure Nurses and the Heart Failure of Society America.
Effects of Nurse-Based Rehabilitation
During the last few years, several meta-analyses have tried to evaluate the effects of heart failure management programs. One recent meta-analysis performed by McAlister et al.2was based on approximately 30 randomized trials of almost 5000 patients that were performed between 1993 and 2004, evaluating the effect of multidisciplinary, often nurse-led, interven- tions with follow-up and patient education sometimes also combined with optimization of treatment. They found that multidisciplinary, often nurse-led, follow-up in a clinic or home- based setting reduced mortality (RR 0.75, 95% CI 0.59–0.96). The numbers needed to treat in order to save one life was 17. The number of
readmissions was decreased by follow-up in a heart failure clinic or home-based setting (RR 0.79, 95% CI 0.68–0.92). Since nurse-based rehabilitation at a quite limited cost reduces readmissions they are cost-effective.2
It was concluded that since nurse-based heart failure rehabilitation has positive effects, it should be considered for all patients hospitalized due to deterioration of heart failure.
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