Transitional care from the hospital to the home in heart failure: implementation of best practices

Nakahara-Melo, Michele; Conceição, Ana Paula da; Cruz, Diná de Almeida Lopes Monteiro da; Püschel, Vilanice Alves de Araújo

doi:10.1590/0034-7167-2021-0123

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TECNOLOGICAL INNOVATION • Rev. Bras. Enferm. 75 (01) • 2022 • https://doi.org/10.1590/0034-7167-2021-0123 copy

Transitional care from the hospital to the home in heart failure: implementation of best practices

Cuidado de transición del hospital al domicilio en la insuficiencia cardíaca: implementación de las mejores prácticas

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

Assess the compliance of the implementation of better evidence in the transitional care of the person with heart failure from the hospital to the home.

Methods:

Evidence implementation project according to the JBI methodology in a cardiology hospital in São Paulo. Six criteria were audited before and after implementing strategies to increase compliance with best practices. 14 nurses and 22 patients participated in the audits.

Results:

In the baseline audit, compliance was null with five of the six criteria. Strategies: training of nurses; reformulation of the hospital discharge form and guidance on self-care in care contexts; and making telephone contact on the 7th, 14th and 21st days after discharge. In the follow-up audit, there was 100% compliance with five of the six criteria.

Conclusion:

The project made it possible to increase the compliance of transitional care practices in people with heart failure with the recommendations based on the best evidence.

Descriptors:
Transitional Care; Heart failure; Nursing Education; Self-Care; Evidence-Based Practice

Audited criteria	Sample	Method (s) used to verify (%) compliance with the criteria
1) Nurses participated in the educational intervention on Transitional Care (TC) of people with Heart Failure (HF).	Nurses Baseline audit: 14 Follow-up audit: 14	Individual questioning to nurses Question: Have you participated in any course/training on TC for people with HF? ( ) Yes ( ) No It will be considered "compliant" if the nurse participated in an educational intervention on TC of people with HF.
2) People with HF/caregivers participated in the educational intervention on important topics for the TC of people with HF.	People with HF/caregivers Baseline audit: 11 Follow-up audit: 11	Individual questioning to the person with HF Question: Have you received any information/training on TC from people with HF? ( ) Yes ( ) No It will be considered "compliant" if the person with HF/caregiver has participated in the conversation circle/bedside on topics relevant to the effective TC.
3) An individual hospital discharge plan was developed and documented in medical records.	Documented individualized discharge plan Baseline audit: 11 Follow-up audit: 11	Evaluation of individualized discharge planning delivered in one copy to the person with HF/caregiver, and another copy attached to the medical record. ( ) Yes ( ) No It will be considered "compliant" if the person with HF received the individualized discharge planning and another copy attached to the medical record.
4) The TC happened in an individual way in order to interconnect the hospital contexts with the outpatient/specialized care.	Individualized discharge plan Baseline audit: 11 Follow-up audit: 11	Evaluation of discharge summary documentation with home care plan and outpatient referral / specialized medical records. ( ) Yes ( ) No It will be considered "compliant" if the discharge planning form has been attached to the medical record.
5) The care needs of people with HF were communicated among health professionals from the hospital and outpatient/specialized care contexts;	Hospital discharge process Baseline audit: 11 Follow-up audit: 11	Evaluation of the discharge process and guidance on the importance of the form for communication with the service to which it was sent. ( ) Yes ( ) No It will be considered "compliant" if the discharge planning form was delivered to the person with HF/caregiver and if the importance of this and the documentation in the medical record was given.
6) Post-discharge follow-up took place to include a combination of home visits and/or telephone or outpatient clinic follow-up.	Telephone contact after hospital discharge Baseline audit: 11 Follow-up audit: 11	Telephone contact with the person with HF and/or caregiver with content: decompensation triggers after discharge, reinforcement of self-care actions and importance of outpatient monitoring. ( ) Yes ( ) No It will be considered "compliant" if the person with HF/caregiver responded to the telephone contact or message (mobile application) in three moments: 7, 14, 21 or 30 days after hospital discharge.

Barriers	Strategies	Resources	Results
Nurses' lack of knowledge about the TC theme of people with HF and their main actions and purposes	Development of an educational intervention with the content: 1) Criteria recommended by the JBI of the CT of people with HF; and 2) Implementation of a protocol on TC for people with HF for all nurses in the sector.	Multimedia with educational content; Training all nurses on the TC of people with HF.	The 14 nurses involved in the project participated in the educational intervention, individually or in a group, totaling seven meetings.
Lack of knowledge on the part of HF patients / caregivers about TC in HF	Creation of a weekly institutional routine of the "Conversation Wheel" about HF and self-care actions	Making playful and educational signs on the subjects covered	Creation of the institutional routine for the weekly holding of the "Conversation Wheel"
Difficulty in exchanging information between nurses in the GCU and outpatient sectors	Reformulation of hospital discharge planning form	Individualized hospital discharge form to interconnect care contexts	Reformulation of the hospital discharge form, in two copies: one was delivered to the person with HF/caregiver, and the other was attached to the patient's medical record.
Follow-up of the patient after hospital discharge	Construction and implementation of a protocol for monitoring patients via telephone contact	Telephone contact in three moments, during the first 30 days after discharge	Telephone monitoring of patients to identify signs and symptoms of HF decompensation

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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[1] Corresponding author: Michele Nakahara-Melo nakahara.michele@usp.br