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Cardiac surgery is associated with postoperative pulmonary complications that increase length of stay (LOS). The literature supports the use of preoperative exercise therapy to improve postoperative outcomes. This practice innovation implemented a home-based exercise program for adult patients who undergo elective cardiac operations. The purpose of this innovation was to decrease LOS and postoperative pulmonary complications in those patients. No statistically significant differences were noted between the 2 groups, however, there was a trend toward decreased LOS in the innovation group. This practice innovation was safe and feasible to implement in an academic hospital.

Background Catheter-associated urinary tract infections are the second most common health care–associated infections, occurring most frequently in intensive care units. These infections negatively affect patient outcomes and health care costs. Local Problem The targeted institution for this improvement project reported 13 catheter-associated urinary tract infections in 2018, exceeding the hospital’s benchmark of 4 or fewer such events annually. Six of the events occurred in the intensive care unit. Project objectives included a 30% reduction in reported catheter-associated urinary tract infections, 20% reduction in urinary catheter days, and 75% compliance rating in catheter-related documentation in the intensive care unit during the intervention phase. Methods This project used a pre-post design over 2 consecutive 4-month periods. The targeted population was critically ill patients aged 18 and older who were admitted to the intensive care unit. A set of bundled interventions was implemented, including staff education, an electronic daily checklist, and a nurse-driven removal protocol for indwelling urinary catheters. Data were analyzed using mixed statistics, including independent samples t tests and Fisher exact tests. Results No catheter-associated urinary tract infections were reported during the intervention period, reducing the rate by 1.33 per 1000 catheter days. There was a 10.5% increase in catheter days, which was not statistically significant (P = .12). Documentation compliance increased significantly from 50.0% before to 83.3% during the intervention (P = .01). Conclusions This bundled approach shows promise for reducing catheter-associated urinary tract infections in critical care settings. The concept could be adapted for other health care–associated infections.

BACKGROUND Approximately 5.7 million people in the United States are diagnosed and living with heart failure (HF), with projected prevalence rates to increase 46% by 2030. Heart failure leads hospital admissions in the United States for individuals 65 years or older, with many acute exacerbation admissions resulting from a lack of medication management, poor patient treatment plan adherence, and lack of appropriate follow-up within the health care system. In 2017, the 30-day HF readmission rate at the facility of implementation was 27%, 3% higher than the national average and, more specifically, 18.5% for the cardiac care unit (CCU). OBJECTIVE The aim of this study was to develop an HF disease management program to reduce 30-day readmission rates for HF patients through the implementation of a structured program including self-care education utilizing the teach-back method, multimodal medication reconciliation, multidisciplinary consultation, telephone follow-up within 48-72 hr of discharge, and follow-up visit within 7-10 days of discharge. PRIMARY PRACTICE SETTING The implementation of the disease management program took place at a major military treatment facility in the continental United States. The facility is a teaching facility housing a 272-bed multispecialty hospital and an ambulatory complex. The implementation took place on the CCU, the primary unit for cardiac admissions, with approximately 30 admissions a month for a primary diagnosis of HF. METHODOLOGY AND SAMPLE In August 2018, a multidisciplinary disease management program was implemented to include patient education utilizing the teach-back method, multimodal medication reconciliation, multidisciplinary consultation, telephone follow-up within 48-72 hr of discharge, and follow-up visit within 7-10 days of discharge. Data were collected and analyzed for 90 days and compared with retrospective data from 2017. FINDINGS Participants in the disease management program had a statistically significant improvement (p < .001) in the hospital readmission rate. The overall 30-day readmission rate decreased from 27% to 10.2% during the implementation period, a decrease of 38%. Ninety-three percent of the patients completed the self-care education, and telephone follow-up was successfully achieved with 96% of these patients. Only 4 patients in the HF disease management program experienced readmission within 30 days. Patients and caregivers reported increased satisfaction with their care due to the disease management program and increased follow-up with care. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE The findings of this innovation suggest that a multidisciplinary disease management program can reduce avoidable 30-day readmissions. The program improved patient follow-up and decreased follow-up appointment no-shows. Multiple participants expressed increased patient satisfaction. The program supports the need for coordinated, interdisciplinary disease management to improve the quality of life of those affected by HF and improve the use of resources to reduce the overall health care burden. Case management is critical to the organized care of HF patients due to the complex, individualized care to achieve optimum patient outcomes.

Heart failure is the leading cause of hospitalizations and readmissions. Guideline-directed medical therapy is the cornerstone to improving outcomes, but less than 20% of patients with heart failure marked by reduced ejection fraction receive target doses. This report reviews the neurohormonal cascade that occurs in heart failure and the role of guideline-directed medical therapy based on the results of landmark trials. In addition, evidence-based strategies to up-titrate medications are described. Nurse practitioners are in an optimal situation to titrate guideline therapy with frequent follow-up and monitoring.

Background: Heart failure (HF) impacts 6.2 million American adults. With no cure, therapies aim to prevent progression and manage symptoms. Inclusion of palliative care (PC) helps improve symptoms and quality of life. Heart failure guidelines recommend the inclusion of PC in HF therapy, but referrals are often delayed. Objective: Introduce PC to patients with HF and examine the impact on PC consults, readmission, mortality, and intensive care unit (ICU) transfers. Methods: Patients (n = 60) admitted with HF to an academic hospital were asked to view a PC educational module. A number of PC consults, re-admissions, mortality, and transfers to the ICU were compared among participants and those who declined. Results: Nine patients in the intervention group (n = 30) requested a PC consult ( P = .042) versus 2 in the usual care group (n = 30; P = .302). There was no statistically significant difference in readmissions, mortality, or ICU transfers between groups. Conclusions: Palliative care education increases the likelihood of PC utilization but in this short-term project was not found to statistically impact mortality, re-admissions, or transfers to higher levels of care.

Background People with atrial fibrillation (AF) have lower reported quality of life and increased risk of heart attack, death, and stroke. Lifestyle modifications can improve arrhythmia-free survival/symptom severity. Shared medical appointments (SMAs) have been effective at targeting lifestyle change in other chronic diseases and may be beneficial for patients with AF. Objective To determine if perceived self-management and satisfaction with provider communication differed between patients who participated in SMAs compared to patients in standard care. Secondary objectives were to examine differences between groups for knowledge about AF, symptom severity, and healthcare utilization. Methods We conducted a retrospective analysis of data collected where patients were assigned to either standard care (n = 62) or a SMA (n = 59). Surveys were administered at pre-procedure, 3, and 6 months. Results Perceived self-management was not significantly different at baseline (p = 0.95) or 6 months (p = 0.21). Patients in SMAs reported more knowledge gain at baseline (p = 0.01), and higher goal setting at 6 months (p = 0.0045). Symptom severity for both groups followed similar trends. Conclusion Patients with AF who participated in SMAs had similar perceived self-management, patient satisfaction with provider communication, symptom severity, and healthcare utilization with their counterparts, but had a statistically significant improvement in knowledge about their disease.

Heart failure with preserved ejection fraction (HFpEF) continues to increase in prevalence with a 50% mortality rate within 3 years of diagnosis, but lacking effective evidence-based therapies. Specific echocardiographic markers are not typically used to trigger alarm before acute HFpEF decompensation. The goal of this study was to retrospectively track changes in echocardiographic markers leading to the time of incident HFpEF hospitalization.In a single-center, retrospective analysis, patients with HFpEF admitted between 2007 and 2014 were identified using the International Classification of Diseases, 9th Revision with search refined using the European Society of Cardiology HFpEF guidelines. Using linear mixed effects models, changes in echocardiographic markers preceding acute HF decompensation owing to incident HFpEF were analyzed. We report on an incident HFpEF cohort of 242 patients, extending 18 years retrospectively, and including 675 echocardiograms analyzed from the overall sample at 14 distinct time intervals before acute decompensation. The regression models demonstrated 3 echocardiographic markers with statistically significant increases across multiple time intervals including, arterial elastance (P = .006), right atrial pressure estimate (P.001), and right ventricular systolic pressure (P = .006). Other echocardiographic markers had individual time intervals with significant increases before acute decompensation, including (a) left atrial diameter, 8 to 10 years before HFpEF diagnosis, (b) left ventricular filling pressure 2 to 6 years before HFpEF diagnosis, (c) ventricular elastance 3 to 6 months before HFpEF diagnosis, and (d) ventricular elastance/arterial elastance as early as 10 to 20 years and as late as 3 to 6 months before HFpEF diagnosis. Furthermore, African Americans presented with incident HFpEF at an average younger age than White patients (65.6 ± 15.2 years vs. 76.7 years ± 11.7, P.001).Noninvasive echocardiographic markers associated with incident HFpEF diagnosis showed long, mid, and acute range, significant changes as far back as 10 to 20 years and as close as 3 to 6 months before acute HFpEF decompensation. Including a diverse study cohort is critical to understanding the phenotypic differences of HFpEF. This hypothesis-generating study identified a novel approach to identifying trends in echocardiographic markers that may be used as a signal of impending incident HFpEF.

Objective We present the design and feasibility testing for the "Digital Drag and Drop Pillbox" (D-3 Pillbox), a skill-based educational approach that engages patients and providers, measures performance, and generates reports of medication management skills. Methods A single-cohort convenience sample of patients hospitalized with heart failure was taught pill management skills using a tablet-based D-3 Pillbox. Medication reconciliation was conducted, and aptitude, performance (% completed), accuracy (% correct), and feasibility were measured. Results The mean age of the sample (n = 25) was 59 (36-89) years, 50% were women, 62% were black, 46% were uninsured, 46% had seventh-grade education or lower, and 31% scored very low for health literacy. However, most reported that the D-3 Pillbox was easy to read (78%), easy to repeat-demonstrate (78%), and comfortable to use (tablet weight) (75%). Accurate medication recognition was achieved by discharge in 98%, but only 25% reported having a "good understanding of my responsibilities." Conclusions The D-3 Pillbox is a feasible approach for teaching medication management skills and can be used across clinical settings to reinforce skills and medication list accuracy.

Background and local problem Patients who take warfarin require frequent testing of their international normalized ratio (INR) level to ensure accurate dosage. Frequent testing can be inconvenient for patients in rural settings, the workforce, the homebound, or those who travel. Patients who have a home INR monitor can test their blood remotely. Methods To circumvent barriers to INR testing, a quality improvement project was designed to implement home INR testing in an anticoagulation clinic setting. Interventions Patients who received a home INR monitor were compared against two usual care testing arms (laboratory and clinic testing patients) in the outcomes of time in therapeutic range (TTR), adverse events, and patient satisfaction using the Duke Anticoagulation Satisfaction Scale (DASS). Results The DASS survey demonstrated the home testing patients had a statistically significant advantage over the clinic testing group in the subdomain of hassles and burdens (p = .048), as well as the lowest overall scores (indicating highest satisfaction) over the clinic testing group (p = .041). No patients in the home testing group had clotting or bleeding issues necessitating hospital admission. There were no significant differences between groups in the TTR analysis (laboratory 70.8%, home 68.9%, and clinic 64.5%) (p = .683). Conclusions Home INR testing provides convenience for patients and reduces the hassles and burdens of warfarin management, leading to improved satisfaction. This engagement in self-care translates to reduced adverse events. Home INR testing can be used in warfarin patients who are highly motivated and willing to engage in their care.

Background Parenteral anticoagulants and vitamin K antagonists (VKAs) have constituted the cornerstone of venous thromboembolism (VTE) treatment. Meanwhile, direct oral anticoagulants (DOACs) provide physicians with an alternative. The Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE observes real-world treatment practices. Objectives Describe initial anticoagulation (AC) treatment patterns in VTE patients who received parenteral AC, VKAs, and/or DOACs within ±30 days of diagnosis. Methods VTE patients were categorized into parenteral AC only, parenteral AC with transition to VKA, VKA only, parenteral AC with transition to DOAC, and DOAC only. Results A total of 9647 patients were initiated on AC treatment alone. 4781 (49.6%) patients received DOACs ± parenteral ACs; 3187 (33.0%), VKA ± parenteral ACs; and 1679 (17.4%) parenteral ACs alone. Rivaroxaban was the most frequently used DOAC (79.4%). DOACs were more frequently used in North America/Australia (58.1%), Europe (52.2%), and Asia (47.6%) than in Latin America (29.7%) and the Middle East/South Africa (32.5%). In patients with suspected VTE, most received parenteral AC monotherapy (67.7%). Patients with deep vein thrombosis were more likely to receive DOACs alone than those with pulmonary embolism with or without deep vein thrombosis (36.2% vs 25.9%). Active cancer patients received parenteral AC alone (58.9%), with 25.5% receiving DOAC ± parenteral AC and 12.8% parenteral AC and VKA. A total of 46.5% of pregnant patients received parenteral AC monotherapy, 34.0% were treated with VKA ± parenteral AC, and 19.5% received a DOAC (± parenteral AC). Conclusion AC treatment patterns vary by patient population, geographic region and site of VTE. Guidelines for AC therapy are not always adhered to.

Hypertension is a leading risk factor for heart disease, stroke, kidney failure, and diabetes and is a predisposing risk factor for most cardiovascular chronic illnesses. The risk for major cardiovascular events drops significantly when guideline-based blood pressure targets are achieved. Several different societies and organizations have released guidelines during the past 6 years, and significant clinical trial data have been recently released. Here, we summarize existing guidelines and recent pertinent clinical trial data to assist practitioners in identifying optimal treatment strategies for the successful management of hypertension.

Despite general efforts to reduce risk factors in cardiovascular disease in the United States over the previous decade, disparities in cardiovascular care remain more prevalent in the underserved population. Recent focus has shifted from treatment of disease to promotion of health. The impact goals for 2020 are improvement in 7 health metrics (smoking status, body mass index, physical activity, healthy dietary score, total cholesterol, blood pressure, and fasting plasma glucose) of cardiovascular health and reduction of cardiovascular disease and stroke by 20%. Identification of those at high risk for poor cardiovascular health in adulthood should begin during early adolescence.

Background Poor adherence to evidence-based medications in heart failure (HF) is a major cause of avoidable hospitalizations, disability, and death. To test the feasibility of improving medication adherence, we performed a randomized proof-of-concept study of a self-management intervention in high-risk patients with HF. Methods Patients with HF who screened positively for poor adherence (

Adults with chronic heart failure (HF) are living longer. Thus, management of symptom exacerbation related to this chronic illness is paramount to improving quality of life and reducing hospitalizations. This article provides key recommendations for nurse practitioners from the 2013 American College of Cardiology Foundation/American Heart Association guideline for how to effectively manage patients with HF, including a review of the major classes of medications to treat chronic HF. The article concludes with a brief discussion of selected areas of new research.

Background STARBRITE, a multicenter randomized pilot trial, tested whether outpatient diuretic management guided by B-type natriuretic peptide (BNP) and clinical assessment resulted in more days alive and not hospitalized over 90 days compared with clinical assessment alone. Methods and Results A total of 130 patients from 3 sites with left ventricular ejection fraction ≤35% were enrolled during hospitalization for heart failure (HF) and randomly assigned to therapy guided by BNP and clinical assessment (BNP strategy) or clinical assessment alone. The clinical goal was resolution of congestion without hypotension or renal dysfunction. In the BNP arm, therapy was adjusted to achieve optimal fluid status, defined as the BNP level and congestion score obtained at the time of discharge. In the clinical assessment arm, therapy was titrated to achieve optimal fluid status, represented by the patient’s signs and symptoms at the time of discharge. Exclusion criteria were serum creatinine >3.5 mg/dL and acute coronary syndrome. Follow-up was done in HF clinics. BNP was measured with the use of a rapid assay test. There was no significant difference in number of days alive and not hospitalized (hazard ratio 0.72, 95% confidence interval 0.41–1.27; P = .25), change in serum creatinine, or change in systolic blood pressure (SBP). BNP strategy was associated with a trend toward a lower blood urea nitrogen (24 mg/dL vs 29 mg/dL; P = .07); BNP strategy patients received significantly more angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and the combination of ACE inhibitor or angiotensin receptor blocker plus beta-blockers. Conclusions BNP strategy was not associated with more days alive and not hospitalized, but the strategy appeared to be safe and was associated with increased use of evidence-based medications.

Background Coping Effectively with Heart Failure (COPE-HF) is an ongoing randomized clinical trial funded by the National Institutes of Health to evaluate if a coping skills training (CST) intervention will result in improved health status and quality of life as well as reduced mortality and hospitalizations compared with a heart failure education (HFE) intervention. Methods and Results Two hundred heart failure (HF) patients recruited from the Duke University Medical Center and the University of North Carolina Hospital system will be randomized to a CST intervention (16 weekly 30-minute telephone counseling sessions including motivational interviewing and individually tailored cognitive behavioral therapy) or to an HFE intervention (16 weekly 30-minute telephone sessions including education and symptom monitoring). Primary outcomes will include postintervention effects on HF biomarkers (B-type natriuretic peptide, ejection fraction) and quality of life, as well as long-term clinical outcomes (hospitalizations and death). Secondary analyses will include an evaluation of treatment effects across subpopulations, and potential mechanisms by which CST may improve clinical outcomes. Conclusions COPE-HF is a proof-of-concept study that should provide important insights into the health benefits of a CST intervention designed to enhance HF self-management, improve health behaviors, and reduce psychologic distress.

Despite the persistent high mortality, many adults are living with chronic heart failure. Recent updates to the clinical guidelines for managing heart failure provide substantive recommendations on how to treat patients with heart failure with preserved ejection fraction or heart failure with reduced ejection fraction. Key changes in these guidelines include 2 new medications, use of biomarkers, a focus on specific comorbidities, and prevention strategies. This report provides recommendations from the updated 2017 guideline for the management of heart failure for nurse practitioners in caring for patients with chronic heart failure.

Objectives The purpose of this study was to assess the impact of changes in symptoms of depression over a 1-year period on subsequent clinical outcomes in heart failure (HF) patients. Background Emerging evidence shows that clinical depression, which is prevalent among patients with HF, is associated with a poor prognosis. However, it is uncertain how changes in depression symptoms over time may relate to clinical outcomes. Methods One-hundred forty-seven HF outpatients with ejection fraction of less than 40% were assessed for depressive symptoms using the Beck Depression Inventory (BDI) at baseline and again 1 year later. Cox proportional hazards regression analyses, controlling for established risk factors, were used to evaluate how changes in depressive symptoms were related to a combined primary end point of death or cardiovascular hospitalization over a median follow-up period of 5 years (with a range of 4 to 7 years and no losses to follow-up). Results The 1-year change in symptoms of depression, as indicated by higher BDI scores over a 1-year interval (1-point BDI change hazard ratio [HR]: 1.07, 95% confidence interval [CI]: 1.02 to 1.12, p = 0.007), was associated with death or cardiovascular hospitalization after controlling for baseline depression (baseline BDI HR: 1.1, 95% CI: 1.06 to 1.14, p < 0.001) and established risk factors, including HF cause, age, ejection fraction, plasma N-terminal pro–B-type natriuretic peptide level, and prior hospitalizations. Conclusions Worsening symptoms of depression are associated with a poorer prognosis in HF patients. Routine assessment of symptoms of depression in HF patients may help to guide appropriate medical management of these patients who are at increased risk for adverse clinical outcomes.

An 86-year-old man presented with acute hepatic failure, worsening thrombocytopenia, and anemia having been diagnosed and managed expectantly with cytogenetically normal RAEB-1. After 20 months a diagnosis of disease transformation to acute monocytic leukemia (M5b) was made. Conventional G-banded analysis of unstimulated bone marrow cultures demonstrated a jumping translocation (JT) involving proximal and distal breakpoints on donor chromosome 3 at bands 3q1?2 and 3q21, respectively. Recipient chromosomes included the long-arm telomeric regions of chromosomes 5, 10, 14, 16, and 19. A low-level trisomy 8 clone was also found in association with both proximal and distal JT clones. Conventional G-banded analysis of unstimulated peripheral blood cultures detected the proximal 3q1?2 JT clone involving recipient chromosome 10 several weeks after transformation to acute monocytic leukemia. Interestingly, JTs involving recipient chromosomes 5, 14, 16, and 19 were not detected in this peripheral blood sample. Palliative care was administered until his demise 2.2 months after disease transformation. There have been fewer than 70 cases of acquired JTs reported in the literature, including one myeloproliferative neoplasm and five acute myeloid leukemias involving a single breakpoint site on donor chromosome 3. Our case is unique as it is the first acquired case to demonstrate a JT involving alternative pericentromeric breakpoint sites on a single donor chromosome consisting of a proximal breakpoint at 3q1?2 and a more distal breakpoint at 3q21.

Poor education-related discharge preparedness for patients with heart failure is believed to be a major cause of avoidable rehospitalizations. Technology-based applications offer innovative educational approaches that may improve educational readiness for patients in both inpatient and outpatient settings; however, a number of challenges exist when implementing electronic devices in the clinical setting. Implementation challenges include processes for “on-boarding” staff, mediating risks of cross-contamination with patients’ device use, and selling the value to staff and health system leaders to secure the investment in software, hardware, and system support infrastructure. Strategies to address these challenges are poorly described in the literature. The purpose of this article is to present a staff development program designed to overcome challenges in implementing an electronic, tablet-based education program for patients with heart failure.

failure: The design and rationale of the Strategies for Tailoring Advanced Heart Failure Regimens in the Outpatient Setting: BRain NatrIuretic Peptide Versus the Clinical CongesTion ScorE (STARBRITE) trial Monica R. Shah, MD, Karen A. Claise, RN, Margaret T. Bowers, NP, Manjushri Bhapkar, MS, Julie Little, NP, Anju Nohria, MD, Laura H. Gaulden, NP, Vickie K. McKee, RN, Kara L. Cozart, Karen L. Mancinelli, MBA, Helen Daniels, Tesca Kinard, Lynne W. Stevenson, MD, Donna M. Mancini, MD, Christopher M. O’Connor, MD, and and Robert M. Califf MD New York, NY, Durham, NC, and Boston, Mass

Background Little data exist to assist to help those organizing and managing heart failure (HF) disease management (DM) programs. We aimed to describe the intensity of outpatient HF care (clinic visits and telephone calls) and medical and nonpharmacological interventions in the outpatient setting. Methods This was a prospective substudy of 130 patients enrolled in STARBRITE in HFDM programs at 3 centers. Follow-up occurred 10, 30, 60, 90, and 120 days after discharge. The number of clinic visits and calls made by HF cardiologists, nurse practitioners, and nurses were prospectively tracked. The results were reported as medians and interquartile ranges. Results There were a total of 581 calls with 4 (2, 6) per patient and 467 clinic visits with 3 (2, 5) per patient. Time spent per patient was 8.9 (6, 10.6) minutes per call and 23.8 (20, 28.3) minutes per clinic visit. Nurses and nurse practitioners spent 113 hours delivering care on the phone, and physicians and nurse practitioners spent 187.6 hours in clinic. Issues addressed during calls included HF education (341 times [52.6%]) and fluid overload (87 times [41.8%]). Medical interventions included adjustments to loop diuretics (calls 101 times, clinic 156 times); β-blockers (calls 18 times, clinic 126 times); vasodilators (calls 8 times, clinic 55 times). Conclusions More than a third of clinician time was spent on calls, during which >50% of patient contacts and HF education and >39% of diuretic adjustments occurred. Administrators and public and private insurers need to recognize the amount of medical care delivered over the telephone and should consider reimbursement for these activities.