Notable Nursing: Update January 2012

January, 2012 - Update

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Notable Nursing: Update - January, 2012

Nurse-Led Programs Help Avoid Heart Failure ReadmissionsNurse-Led Programs Help Avoid Heart Failure Readmissions

Nurse leaders throughout Cleveland Clinic hospitals are learning that preparing acute care patients for discharge and educating patients and their caregivers begins at admission, that it must be reinforced throughout the hospitalization and after the patient is discharged home or to a care facility. Gone are the days when acute care focused exclusively on hospital procedures and the inpatient stay.

Jackie Spence, BSN, RN, Nurse Manager, Cardiovascular Nursing, and Terri Murray, BSN, RN, Nurse Manager, Heart and Vascular Unit, at Cleveland Clinic’s Heart & Vascular Institute, are ramping up efforts to reach heart failure patients. “A family class we offer focuses on heart healthy living,” says Spence. “We have a total of six classes a week, held at different times, so our classes mesh with caregiver schedules. We have a chance to do one on one because classes are small with usually three to four patients.” The classes are advertised prominently in patient rooms and day rooms.

“Everything we teach is very simple,” says Murray, “whether we are focusing on food labels, weight gain, or medications.” Laminated cards that patients can post on their home refrigerators show a bulleted list of key self management tips: weighing themselves each morning before breakfast and tracking it, taking medicine as prescribed, and checking for any swelling or chest pain.

“Heart failure ‘zones’ on the patient education cards are very important in our teaching and we try to get across what each zone means for the patient. A green all-clear zone, a yellow zone where the patient may have no energy and a dry hacky cough, and a red zone when you must call the doctor because of severe shortness of breath, chest pain, or confusion,” says Spence.

Another strategy that is being used throughout Cleveland Clinic’s hospitals is the teach-back method, where patients are asked to explain back to nurses what they were taught in their own words. It’s a technique Donna Ross, MSN, RN, Clinical Nurse Specialist and Heart Failure Coordinator, Lakewood Hospital, finds invaluable in determining whether patients understand how to take their medicines and monitor their condition. “Having patients tell us in their own words what they are supposed to do quickly shows us that they understand how to take care of themselves.”

Annette Fogarty, MSN, RN, Heart Failure Coordinator and Advanced Practice Nurse at Fairview Hospital, knows that heart failure care is complicated. She sees the “biggest need as being sure that the next caregiver knows how to manage these patients.” She also knows that many patients don’t come in with a primary diagnosis of heart failure, yet have it. “Many patients come in with an infection or a respiratory problem, yet still need the knowledge to manage the symptoms of heart failure. Once the patients are identified, we make sure that it is listed and that they are part of our teaching and preparing for discharge.” Fogarty says all of Fairview’s education is multidisciplinary and collaborative, involving pharmacy, nursing and dietary, with preparation for discharge starting at admission. Prior to discharge, follow-up care is scheduled by the nursing staff through the Hospital-to-Home Initiative. At each facility, patients are given one number to call if they have questions. These programs are expanding across Cleveland Clinic hospitals and a new bar is being set for heart failure outcomes.

Notable Nursing: Update - January, 2012

Rethinking Hospital Readmissions and Transitioning Home: Best Practices

The Centers for Medicare & Medicaid Services call for hospitals to reduce unnecessary readmissions has opened the door for innovative programs in transitional care. A team of advanced practice nurses from Cleveland Clinic’s Heart Care at Home Program, working with cardiac care physicians and home care staff, is using new strategies to help patients go home better informed and able to manage their heart failure.

“We want Cleveland Clinic to be the best place for patients to come and the best at safely returning people home,” says Steve Landers, MD, Cleveland Clinic’s Director of Home Care. “We are starting with the premise that we want to successfully transition people home.” Within the past year and one-half, a strong partnership between Cleveland Clinic’s Home Care Agency and the Heart & Vascular Institute has laid the cornerstone for a high-quality transitional care program for cardiac patients.

Cleveland Clinic’s transitional care program caters to patients with heart failure, heart attack and heart surgery. Helen Conroy, MSN, RN, Director of Cleveland Clinic’s Care Management Department, says: “We try to make sure we have an RN at the bedside asking the important questions for discharge. Can someone drive you to your appointments? Can you afford your medications?”

“Care transitions begin as soon as the patient is admitted,” said Eiran Gorodeski, MD, heart failure cardiologist at Cleveland Clinic. “Nurses visit patients when they are hospitalized, and begin a coaching regimen. We try to focus on care coordination, the importance of appointments, and red flags that would indicate needing care.”

Making sure patients understand their medicines is paramount. “We use the ‘Ask 3 – Teach 3’ teach-back method, where patients are taught, and then asked three things: the name of the medication, why they need to take it and what the possible side effects are,” says Deborah Brosovich, MA, RN, CCRN, Assistant Clinical Director of Nursing, for Cleveland Clinic’s Heart & Vascular Institute. “A teach-back video developed at Cleveland Clinic teaches nurses how to use the technique. Now, it is utilized in all areas of patient education, including diagnosis, signs and symptoms, when and who to call if red flags occur, and for follow-up appointments.”

The amount of education these patients require is challenging, according to Katie McGhee, MBA, RN, Department Manager IV, Care Management. “The nature of our job is to ensure that patients receive efficient and effective care while in the hospital and after discharge.”

Remote Monitoring, National Scope

With insurer funding, Cleveland Clinic nurses are also launching pilot transitional care initiatives. “We are launching a discharge letter pilot due to us often being required to set up care out of state following discharge,” says Conroy. “The pilot involves specific extended care facilities that are receiving patients from us with a diagnosis of heart failure. Case managers are identifying these patients upon discharge and notifying the Physician Referral Center, who in turn generates a letter within 24 hours to the extended care facility summarizing their care and treatment.”

The discharge letter pilot is another effort to reduce readmissions of heart failure patients who are first going to these specific facilities before transitioning home, explains Conroy.

Dr. Gorodeski adds: “Because we treat patients from around the country and around the world, we need to come up with ways to take care of patients who live far away. We want to grow our program – identifying nurse practitioners as leaders in this new transitional care field.”

Another aspect of growing the program is cutting-edge communications and technology, according to Dr. Gorodeski. “For patients in Northeast Ohio, we hope to add videoconferencing in patients’ homes so our nurses can communicate with patients face-to-face, not just over the phone. We are also about to launch a research study with a remote monitoring device that is placed under a patient’s mattress, monitoring them while they are sleeping, so we get a better picture of their progress and how we can take care of them.

There are certainly barriers to success. Dr. Landers said: “Our hardest situations occur when people’s basic needs may not be met – if the person doesn’t have safe, secure housing, food, and clothing, and if there is cognitive impairment.” That said, with stepped-up efforts, “we’ve dropped our home health hospitalization rate down from 28% in 2008 to 18% this year.” Hospital staff may fear transitional care, but Dr. Gorodeski stressed: “Doing it well is going to prove to be a strategic advance.”

Notable Nursing: Update - January, 2012

Building a “Great New Partnership”: Collaborating with SNFs for Better Outcomes

Since May, Cleveland Clinic has been following the heart failure patients it discharges to skilled nursing facilities (SNFs), offering education and advocating for their healthy return home.

Carol Hall, MSN, RN, CNP, SNF Transitional Care Program Coordinator for Cleveland Clinic’s Heart Care at Home program, spends her days traveling between main campus and five SNFs in Northeast Ohio to help those patients. The goal of the program is to reduce avoidable readmissions to the hospital and ensure the patient transitions to home after his or her SNF stay.

Hall, who sees 13 to 18 patients each week, coordinates their care as they transition from the hospital to the SNF to their own homes. Patients typically spend about 16 to 30 days in a SNF. During their transitional care, Hall collaborates with the patients’ physicians, identifies the patients’ risk of readmission, holds care conferences between the various providers and makes sure the patients are attending their follow-up appointments once they leave the SNF.

Denise Trun, RN, Director of Nursing at Menorah Park Center for Senior Living in Beachwood, Ohio, says the work Hall does offers her facility “a great, new partnership with Cleveland Clinic” and is helping to facilitate better patient outcomes by providing continuity of care along with immediate access to heart failure experts at Cleveland Clinic.

Once they are home, Cleveland Clinic’s Heart Care at Home program supports these same patients in maintaining their health.

Heart Care at Home provides personal support to allow patients to recover successfully in the comfort of their own home following hospitalization for heart disease or heart surgery. The program typically lasts 40 days after discharge and uses innovative telehealth home-based monitoring technology to monitor patients’ progress daily and track blood pressure, heart rate, weight, blood oxygen level and other vital signs. The telehealth technology transmits data through the patient’s home phone line to a care center staffed by home care nurses. These nurses update physicians regularly on their patients’ progress and follow-up with the patient or his or her caregiver by phone, as needed, to answer questions and provide support. If needed, a home care nurse may be sent to the patient’s home.

“If a patient is sick enough to be at Cleveland Clinic for heart care, then he or she needs close follow-up when discharged,” Hall says. “Sometimes this requires staying in an SNF that is close to Cleveland Clinic.” She adds that several local SNFs have partnered with the Cleveland Clinic Heart Care at Home Transitional program and have incorporated its heart failure protocol into their work flow.

Maureen O’Malley, MSN, CNP, CHFN, works in Cleveland Clinic’s Section of Heart Failure and Cardiac Transplantation managing follow-up care of heart patients once they have been discharged. Much of that management involves educating patients about how to take care of themselves post-discharge.

“Education plays a big part in the successful outcome of each patient,” O’Malley says. “They’re not going to have a nurse with them for the rest of their lives so it’s important for them to know when to call us, why to call and the signs and symptoms of heart failure.”

She has collaborated with nurses to figure out the most important information that can be given to heart patients when they are discharged home or to a SNF. This, she says, helps the patients focus on self-care techniques that are essential immediately upon discharge.

“Patients aren’t going to retain all of the information they’re given on the floor,” O’Malley says. “We try to stick to certain key things.”

O’Malley and her colleagues refer patients to dietitians for education about nutrition. Pharmacists see the patients prior to discharge to help them understand and manage their medications. Most importantly, she stresses to patients the significance of self-monitoring, weight, sodium and fluid restrictions, exercise and medications.

She and some colleagues from across the health system are working on a booklet that provides guidance to patients. The goal is to create one consistent source of information so every heart failure patient, discharged from any facility within the Cleveland Clinic health system, is receiving the same instructions.

Coinciding with the goal of building a system wide education tool for all heart failure patients, the Heart Care at Home Transitional program is taking steps to build its network of support to help these patients regain their independence. “To grow the program, we need to expand out to our partners, including more SNFs and the EDs for 24-hour needs,” says Hall.

Notable Nursing: Update - January, 2012

Invigorating Advanced Nurse Education, Practice for Quality & CollaborationIOM Report Update: Invigorating Advanced Nurse Education, Practice for Quality & Collaboration

Since the Institute of Medicine released its report, The Future of Nursing: Leading Change, Advancing Health, in October 2010, Cleveland Clinic nurses have launched several initiatives aligned with the report’s four directives.

One of those initiatives is to increase awareness and understanding of the role of the nearly 800 advanced practice nurses (APNs) throughout the Cleveland Clinic health system. And Meredith Lahl, MSN, PCNS-BC, PNP-BC, a pediatric clinical nurse specialist and nurse practitioner who took on the role of Senior Director of Advanced Practice Nurses in September, is leading the charge. <;/p>

“We recognize it is important for physicians and other healthcare providers to understand the role and importance of the APN,” Lahl says. She adds that a greater understanding on the part of physicians may result in more effective relationships between physicians and patients and nurse practitioners (one type of APN) and patients. It has become increasingly common for patients to be seen by a nurse practitioner in addition to, and sometimes in lieu of, their physician.

In addition to nurse practitioners, APNs include clinical nurse specialists, nurse anesthetists and certified nurse midwives. Lahl and her team are currently performing an assessment of the Clinic’s entire health system and all of the different settings in which APNs practice.

“Our goal is to get a handle on what they do, how they practice and what the role of the APN is in each practice setting,” Lahl says. With that information she can begin the work of standardizing best practices and making sure each APN is practicing to the broadest scope of his or her abilities.

A part of all APNs’ practice is quality monitoring. Depending on the type of APNs they are, they may utilize patient chart reviews or practice reviews. These tools, which have been standardized across the health system, are outcomes-based self and peer evaluations designed to give constructive feedback to the APNs regarding their work performance.

In an effort to promote education of the APNs themselves, Lahl is working on offering specialty-specific continuing education programs and a comprehensive orientation program for APNs new to the system. Also being considered in the long term is an APN residency program.

For more on the Zielony Nursing Institute’s initiatives invigorated by the IOM report, go to Notable Nursing Fall 2011 issue.

The four directives issued in the Institute of Medicine’s report, The Future of Nursing: Leading Change, Advancing Health:

  • Nurses should practice to the full extent of their education and training.
  • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
  • Nurses should be full partners, with physicians and other healthcare professionals, in redesigning health care in the United States.
  • Effective workforce planning and policy making require better data collection and information infrastructure.

Notable Nursing: Update - January, 2012

Reducing Fluids May Offer Better Quality of LifeResearching Methods to Prevent Readmissions: Reducing Fluids May Offer Better Quality of Life

Patents with heart failure are often fluid overloaded when they are admitted to the hospital. At discharge, they may still have excess vascular or interstitial fluid.   Early post-discharge, new or worsening fluid overload can prompt signs and symptoms that may reduce health-related quality of life. Currently at discharge, patients are advised to follow a 2,000-milligram sodium/day diet to help maintain euvolemia. In addition, some patients may be asked to follow a fluid restriction of 2-liters/day. While national guidelines for managing chronic heart failure include fluid restriction for patients with advanced heart failure or for those who have frequent rehospitalizations or are hyponatremic, there are very few research studies that provide evidence of the benefit of fluid restriction on outcomes after hospitalization for decompensated heart failure.

“In my review of the literature, Italian researchers found outcome benefits in patients with chronic heart failure who were randomized to follow a very strict fluid restriction of 1-liter/day and a moderate dietary sodium intake of 2,700-milligrams/day,” says Nancy Albert, PhD, CCNS, CHFN, CCRN, NE-BC, Director of Nursing Research & Innovation at Cleveland Clinic. “Patients who were managed with a strict fluid restriction and a moderate dietary sodium level/day had fewer rehospitalizations and less neuroendocrine hormone activation at 6-month follow-up.” 1

Incited by the possibility of better clinical outcomes in patients who followed a strict fluid restriction, Albert initiated a randomized controlled pilot study to investigate the effects of hospital discharge advice on fluid restriction. In the study, patients with heart failure and a serum sodium of 137 mg/dL or less were randomized to usual care fluid recommendation instructions (UC group, N = 26) or a 1-liter/day fluid restriction, in addition to education on how to manage thirst and signs of dehydration (1L group, N = 20). Assessments at 60-days included health related quality of life (QoL) by Kansas City Cardiomyopathy Questionnaire (KCCQ; primary outcome), and the following secondary outcomes: emergency department care, rehospitalization, thirst, adherence to fluid restriction and difficulty in following fluid restriction. Outcomes were compared at 60-days by Pearson’s chi-square, Wilcoxon rank sum and two-sample T-tests.

“In our study, patients in the intervention group were given advice on following a very strict fluid restriction of 4-cups/day or 1-liter/day. They received education on managing fluid intake and quenching thirst, measuring fluids and recognizing signs of mild to severe dehydration,” explains Albert. “They were also given a phone number to contact me if they developed signs of dehydration. Throughout the study I didn’t receive any phone calls. Overall, patients seemed to tolerate the fluid restriction advice very well.”

Of 47 patients, mean age was 62.8 ± 12.8 years, 46 percent were Caucasian, 50 percent had ischemic cardiomyopathy and lowest mean (SD) serum sodium level during hospitalization was 132.9 (± 3.2) mg/dL. There were no differences by group in baseline demographics, comorbidities and health-related QoL; however, more UC patients had New York Heart Association-functional class (NYHA-FC) III/IV status (89.5 percent versus 80 percent, P = 0.03) and more 1L group patients had a history of fluid restriction (P = 0.031) before enrolling in this study. Of 20 patients in the 1L group, only 13 (65 percent) were adherent by self-report at 60-days. Using intent-to-treat analysis, at 60-days, there were no differences by group in fluid restriction behaviors (such as purchasing fluids in smaller bottles/containers and keeping fluids out of sight); although the 1L group trended toward better adherence to fluid restriction behaviors (P = 0.11). There were also no differences by group in sense of thirst or difficulty adhering to discharge instructions about fluid restriction.

“However, when we looked at the quality of life scores, we saw differences by group assignment,” says Albert. “Quality of life improved in patients in the 1-liter/day group compared to those in the usual care group at 60-days. Compared to patients randomized to usual care, quality of life scores were significantly better in the 1-liter/day group for symptom burden, total symptoms, overall quality of life summary score and clinical quality of life summary score. Additionally, the 1-liter/day group had a trend toward better quality of life in physical limitations, symptom frequency and self-efficacy. Based on our pilot study results, many aspects of 60-day heart failure-related quality of life were better in patients who followed a 1-liter/day fluid restriction,” Albert explains.

There were no differences by group in median number of ED care or heart failure hospitalizations at 60-days. However, the study was not powered to determine differences between groups in these outcomes; they were included to assess trends.

In a European observational research study in which investigators assessed level of thirst in patients who followed either a strict or moderate fluid restriction, patients following a strict fluid restriction complained of more thirst.2 Albert and her colleagues did not find statistically significant differences between groups in sense of thirst or in difficulty adhering to the fluid restriction instructions over the 60-day period. “What was most surprising to me is that we expected more patients in the 1-liter/day group to have thirst distress -- the fact that we had no differences between groups was a good surprise,” she says.

Albert credits her study’s decreased thirst distress in the 1-liter/day group to comprehensive patient education about ways to combat thirst without drinking excess fluid. Tactics included sucking on hard candy and frozen fruit pieces to quench thirst and avoidance of milk products.

The study’s one caveat was that patients had to have a serum sodium level of 137 mg/dL or less to be enrolled. Albert would like to investigate 1-liter/day fluid restriction in a larger sample and one that does not include exclusions based on serum sodium level.

“Our current results provide preliminary outcomes that fluid restriction might be beneficial in improving quality of life after hospital discharge. Further, using a larger sample, we need to learn about potential effects of the intervention on rehospitalization. Before making a 1-liter/day fluid restriction a standard of care -- even for the first 60-days after hospital discharge -- more research is necessary and physicians and other licensed independent providers must be willing to allow their patients to be enrolled in this type of research,” says Albert. “It may be premature to ask all patients to follow a 1-liter/day fluid restriction at hospital discharge. Knowledge gained by the results of this pilot study will lead to new research that can give us a clearer understanding of it’s benefits, especially in reducing early rehospitalization.”


1. Parrinello G, Di Pasquale P, Licata G, et al. Long-term effects of dietary sodium intake on cytokines and neurohormonal activation in patients with recently compensated congestive heart failure. J Cardiac Fail. 2009;15:864-873.

2. Holst M, Strömberg A, Lindhom M, Willenheimer R. Description of self-reported fluid intake and its effects on body weight, symptoms, quality of life and physical capacity in patients with stable chronic heart failure. J Clin Nurs. 2008;17(17):2318-2326.

Notable Nursing: Update - January, 2012

Grant Supports ExcellenceGrant Supports Excellence in ICU Competency and Self-Confidence: Advancing the Science of Nursing Regulation through Simulation

A $158,000 grant from the National Council of State Boards of Nursing Center for Regulatory Excellence (CRE) was recently awarded to Cleveland Clinic’s Department of Nursing Education & Professional Practice Development. The CRE grant, entitled, “Evaluating the Use of Human Patient Simulation (HPS) to Improve Critical Thinking Competencies and Perceived Self-Confidence of New Graduate Nurses in the Intensive Care Unit (ICU),” aims to advance the science of nursing regulation by using simulation throughout the orientation period. Educational efforts from the grant’s support will act in collaboration with the Cleveland Clinic Multidisciplinary Simulation Center and Cleveland State University.

The CRE grant will allow Cleveland Clinic investigators to explore solutions for transition-to-practice gaps seen in ICU nursing. Through an intensive educational program utilizing six simulated patient care scenarios, the study sample of 150 inexperienced ICU registered nurses will address patients with diabetes, respiratory distress, acute renal failure, hypovolemic shock and myocardial infarction. A randomized trial, half of the study participants will be exposed to traditional orientation methods while the remaining half will undergo traditional orientation plus the immersion method.

“From the six patient scenarios that participants will manage [in simulation], two of the things we’re looking for are early recognition and early communication of the conditions they are seeing. They will have the opportunity to make a mistake and see what the consequences are without a real patient,” says primary investigator, Christine Szweda, MS, BSN, RN, NE-BC, Senior Director, Operations, Nursing Education at Cleveland Clinic. “The most important part is the debriefing after each simulation with regard to what they were thinking, what was their rationale, what they would do differently now and how they would apply this on the floor.”

The study will be based on a quasi-experimental design with additional qualitative data. The simulated patient care scenarios will immerse nurses in decision making related to patient problem identification, level of urgency and managing patient care problems. A weeklong educational program will be provided to each immersion orientation group for five months. At the end of five months, data will be analyzed to determine if there is a significant difference between PBDS scores and/or perceived self-confidence in the two groups and identify themes in qualitative data.

“We want to take a group that is particularly interested in ICU nursing, expose them to more in-depth situations and determine if that experience alone will help improve the outcomes of what’s officially called critical thinking,” says co-investigator, J. Eric Jelovsek, MD, Director of the Clinic’s Multidisciplinary Simulation Center, which is designed to enhance the clinical learning experience for healthcare professionals. “This will basically give them the opportunity to not only be exposed to what this might look like in a more realistic environment, but then also dive deep after the event and really go over what happened.”

“If we show success with our study of ICU nurses, I believe this will help develop a standard for training and we will have something to share nationally through a patented program that works,” says Szweda. “Our efforts will help address the transitions-to-practice gap that occurs across the country.”