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SUPPORTING REGISTERED NURSES TO FACILITATE ADVANCE CARE PLANNING (ACP) IN HEART FAILURE PATIENTS
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symptomatic or life-threatening arrhythmias and advanced heart failure. At our centre, approximately 60 device implant procedures are performed each month in a dedicated implant room on the interventional cardiology unit. These devices include; loop recorders, pacemakers, internal cardioverterdefibrillators and cardiac resychronization therapy devices. The device implant room is an increasingly complex environment and is staffed by a multidisciplinary team which may include electrophysiology physicians, cardiac surgeons, radiology technologists and registered nurses. A high degree of vigilance and streamlined patient care processes are necessary to optimize safety in the device implant room. In 2014, our multidisciplinary team developed and implemented practice and system changes within our device implant room aimed at improving patient care and safety. The purpose of this presentation is to describe the strategies we developed and share the outcomes of this quality improvement initiative. These strategies included changing the workflow in the implant lab, improving nursing education, refining safety check-lists and embedding safety mechanisms into the documentation. In collaboration with the entire implant team, outcomes of these changes are reviewed on a bi-monthly basis. Communication and multidisciplinary teamwork became more effective by incorporating these changes into the device implant room. The safety mechanisms we introduced added a heightened degree of team accountability and optimized patient care.
N020 IMPROVING DELIRIUM MANAGEMENT ¼ A NURSING INTERVENTION INVOLVING FAMILY CAREGIVER: FINAL RESULTS FROM A RANDOMIZED PILOT STUDY T Mailhot, S Cossette, A Denault, Y Lamarche, M-C Côté, M-H Carbonneau, A Brisebois Montreal Heart Institute, Montreal, QC
Delirium gravely affects elderly cardiac patients and their family caregivers (FC) who report feelings of anxiety and ask to be more involved. Aim: Assess the feasibility, acceptability, and preliminary efficacy of a nursing intervention mentoring FC in delirium management. In comparison to participants not receiving the intervention, those who do, will show less severe delirium (patients), less anxiety and higher self-efficacy (FC). Methods: In this two-group (usual care versus intervention) randomized pilot study (n ¼ 30 dyads - patients and FC). Consent is obtained from FC at delirium onset followed by randomization and group assignment. The intervention is based on a caring relationship and Bandura’s principles to foster the FC’s self-efficacy. The intervention nurse’s objective is to mentor the FC so he becomes an active partner who intervenes with the delirious patient, possibly leading to less severe delirium manifestations (e.g.: recalls the reasons for hospitalization). Analyses: The primary indicator of acceptability is obtaining consent from 75 % of approached FC. For the preliminary efficacy, data is collected from validated
Canadian Journal of Cardiology Volume 31 2015
measures of delirium (Confusion Assessment Method and Delirium Index) and participants’ responses to questionnaires. Results: 28/30 dyads are included. We obtained consent from 71% of approached FC (11 refusals out of 39 approached) and no refusals from patients after delirium. The trial is ongoing; analyses on preliminary efficacy are not performed yet. This study will provide nurses with tools to work with families during delirium. The final results and implications for practice will be described.
N021 NURSE PRACTITIONER MANAGED RAPID ACCESS CLINIC: A STRATEGY TO PREVENT HEART FAILURE READMISSION E Estrella-Holder, S Zieroth St. Boniface Hospital, Winnipeg, MB
Heart failure (HF) is a significant public health concern affecting patients, families and communities. There are approximately 500,000 Canadians afflicted with HF with an estimated 50,000 new cases per year. Despite advances in the treatment of this chronic condition, frequent hospital readmissions are of particular interest. HF is one of the leading causes of hospital readmissions within 30 days of discharge. The transition period from hospital discharge to maintenance outpatient care is a high risk phase of the care trajectory that patients with HF encounter. Several interventions to reduce HF readmissions have been developed and implemented. A cardiovascular Nurse Practitioner (NP) managed post hospital discharge clinic was developed as a pilot project to determine if a rapid post hospital discharge follow-up by a NP within two weeks of discharge prevents hospital readmission. This presentation will describe the process used in the project and the preliminary findings of this approach to heart failure care. The preliminary results of the 18 patients enrolled in this on-going pilot project revealed no hospital readmissions or emergency room visits within 60 days post discharge. In addition, all patients with NYHA functional class IV status on hospital admission showed improvement or stabilization in NYHA functional status to I-II as well as improvement in their Minnesota Living with Heart Failure Scores. Based on these preliminary findings, a cardiovascular NP managed rapid access clinic can potentially prevent or reduce HF readmissions. It is an innovative outpatient care strategy that may help improve outcomes of patients discharged with HF.
N022 SUPPORTING REGISTERED NURSES TO FACILITATE ADVANCE CARE PLANNING (ACP) IN HEART FAILURE PATIENTS F Lau Toronto General Hospital, Toronto, ON
The illness trajectory of heart failure is characterized by periods of stability and acute exacerbations in which death becomes increasingly probable. As such, the Canadian
Abstracts
Cardiovascular Society’s Heart Failure Management Guideline (2011) strongly encourages heart failure patients to have advance care planning (ACP) or advance directives in place to improve quality patient-centered care. Research has demonstrated that clinicians often do not have adequate knowledge and skills to facilitate ACP. There is a need to address this identified gap, because literature indicated that some patients and families were ready to discuss ACP if clinicians initiated these conversations. The Registered Nurses Association of Ontario (RNAO) clinical fellowship provided an opportunity to advance clinical practice on developing knowledge and skills for facilitating ACP. During the fellowship, a four hours education session adapted from a communication skill training program was developed and presented to twelve Registered Nurses (RN) on the In-Patient Cardiology Unit. The session consists (a) didactic teaching on ACP and a communication theory; (b) identification of individual goals; (c) role-play in small groups and receipt of a pocket-sized communication cue card; (d) and development of personal goals for incorporating ACP in daily clinical practice. The pre and post-workshop evaluation showed that nurses’ self-reported confidence in facilitating ACP increased from 60% to 86%. Based on results of the evaluation, there is a potential for RN to increase ACP discussions at the actual clinical setting. Similar education session may be effective in other clinical areas to support RN in facilitating ACP conversations.
N023 TIME TO TALK...THE DEVELOPMENT AND IMPLEMENTATION OF A CARDIAC SURGERY HANDOVER TOOL D Schmidt,1 C Lazarenko,2 A Ferland2 1
Foothills Medical Centre, Calgary, AB
2
Alberta Health Services, Calgary, AB
Communication breakdown has been cited by healthcare safety experts as responsible for 75% of errors in healthcare. Studies have shown that clinical information important to physicians and nursing staff is often lost during patient transfer. Interdisciplinary handover between the Cardiovascular Intensive Care Unit (CVICU) and Step-down Unit 91(U91) at Foothills Medical Centre was not standardized. Inconsistencies and deficiencies were recognized anecdotally and through surveys in the handover of this patient information. An opportunity to create a clinical handover tool to optimize and standardize interdisciplinary communication was recognized. A working group was assembled to create a standardized clinical handover tool to be utilized in greater than 90% of patient handover between inter/intra disciplinary teams in CVICU and U91. The successful implementation of this tool resulted in a structured, retrievable, and easily accessible reporting system, where clinically relevant information is presented efficiently and succinctly. Over a period of twelve months, through multiple PLAN/ DO/STUDY/ACT cycles, a handover tool was created with
S321
the input of a multidisciplinary stakeholder group. Post implementation surveys and interviews demonstrate the handover tool has improved consistency of information transferred, reduced the incidence of missed information on transfer and increased awareness of the importance effective communication. Currently, 95% of patient transfers from CVICU to U91 are completed using the handover tool. Surveys completed by receiving staff demonstrate increased satisfaction with the transfer process, and an overall sense of increased confidence in patient care with the information received on the tool.
N024 YOUNG ADULTS COPING WITH A LEFT VENTRICULAR ASSIST DEVICE: A CASE STUDY T Morgan, S Gibson, A Bonaldo, A Storlarik, S Macdonald University of Ottawa Heart Institute, Ottawa, ON
For many young adults making the transition to adulthood can be challenging and stressful. This is a phase in life that is characterized by making career choices, leaving home and becoming independent from their parents, and possibly finding a partner. However, for a young adult living with a left ventricular assist device (LVAD) this phase of life is so much more complicated because a critical illness subverts this developmental process. The young adult is surrounded by equipment that cannot be ignored and is reminded constantly of the risk of death. The new normal is a life on standby, isolation from peer groups, limitations in activity and feeling confined, lack of privacy, living with anticipatory fear and dependence on others for support. Goals for the future are put on hold and independence is a dream. Hospitalization, frequent medical appointments, medications and technology are the new reality for this patient group. Through the use of a case study, this presentation will describe the successful, complex and innovative nursing strategies that were implemented to help the young adult patient cope with living with a device.
N025 END-OF-LIFE CARE IN HEART FAILURE PATIENTS WITH IMPLANTABLE CARDIOVERTER DEFIBRILLATOR: AN INTERDISCIPLINARY APPROACH B Gregorio, L Gallagher Southlake Regional Health Centre, Newmarket, ON
According to the Public Health Agency of Canada (2012) heart failure (HF) affects more than 485,000 Canadians. The Canadian Cardiovascular Society Guidelines for HF management (2014) incorporate device therapies for the prevention of sudden cardiac death and/or improvement of HF symptoms. However, research has shown that in the last weeks of their lives, 20% of patients with implantable cardioverter defibrillators (ICDs) receive shocks that are painful and
symptomatic or life-threatening arrhythmias and advanced heart failure. At our centre, approximately 60 device implant procedures are performed each month in a dedicated implant room on the interventional cardiology unit. These devices include; loop recorders, pacemakers, internal cardioverterdefibrillators and cardiac resychronization therapy devices. The device implant room is an increasingly complex environment and is staffed by a multidisciplinary team which may include electrophysiology physicians, cardiac surgeons, radiology technologists and registered nurses. A high degree of vigilance and streamlined patient care processes are necessary to optimize safety in the device implant room. In 2014, our multidisciplinary team developed and implemented practice and system changes within our device implant room aimed at improving patient care and safety. The purpose of this presentation is to describe the strategies we developed and share the outcomes of this quality improvement initiative. These strategies included changing the workflow in the implant lab, improving nursing education, refining safety check-lists and embedding safety mechanisms into the documentation. In collaboration with the entire implant team, outcomes of these changes are reviewed on a bi-monthly basis. Communication and multidisciplinary teamwork became more effective by incorporating these changes into the device implant room. The safety mechanisms we introduced added a heightened degree of team accountability and optimized patient care.
N020 IMPROVING DELIRIUM MANAGEMENT ¼ A NURSING INTERVENTION INVOLVING FAMILY CAREGIVER: FINAL RESULTS FROM A RANDOMIZED PILOT STUDY T Mailhot, S Cossette, A Denault, Y Lamarche, M-C Côté, M-H Carbonneau, A Brisebois Montreal Heart Institute, Montreal, QC
Delirium gravely affects elderly cardiac patients and their family caregivers (FC) who report feelings of anxiety and ask to be more involved. Aim: Assess the feasibility, acceptability, and preliminary efficacy of a nursing intervention mentoring FC in delirium management. In comparison to participants not receiving the intervention, those who do, will show less severe delirium (patients), less anxiety and higher self-efficacy (FC). Methods: In this two-group (usual care versus intervention) randomized pilot study (n ¼ 30 dyads - patients and FC). Consent is obtained from FC at delirium onset followed by randomization and group assignment. The intervention is based on a caring relationship and Bandura’s principles to foster the FC’s self-efficacy. The intervention nurse’s objective is to mentor the FC so he becomes an active partner who intervenes with the delirious patient, possibly leading to less severe delirium manifestations (e.g.: recalls the reasons for hospitalization). Analyses: The primary indicator of acceptability is obtaining consent from 75 % of approached FC. For the preliminary efficacy, data is collected from validated
Canadian Journal of Cardiology Volume 31 2015
measures of delirium (Confusion Assessment Method and Delirium Index) and participants’ responses to questionnaires. Results: 28/30 dyads are included. We obtained consent from 71% of approached FC (11 refusals out of 39 approached) and no refusals from patients after delirium. The trial is ongoing; analyses on preliminary efficacy are not performed yet. This study will provide nurses with tools to work with families during delirium. The final results and implications for practice will be described.
N021 NURSE PRACTITIONER MANAGED RAPID ACCESS CLINIC: A STRATEGY TO PREVENT HEART FAILURE READMISSION E Estrella-Holder, S Zieroth St. Boniface Hospital, Winnipeg, MB
Heart failure (HF) is a significant public health concern affecting patients, families and communities. There are approximately 500,000 Canadians afflicted with HF with an estimated 50,000 new cases per year. Despite advances in the treatment of this chronic condition, frequent hospital readmissions are of particular interest. HF is one of the leading causes of hospital readmissions within 30 days of discharge. The transition period from hospital discharge to maintenance outpatient care is a high risk phase of the care trajectory that patients with HF encounter. Several interventions to reduce HF readmissions have been developed and implemented. A cardiovascular Nurse Practitioner (NP) managed post hospital discharge clinic was developed as a pilot project to determine if a rapid post hospital discharge follow-up by a NP within two weeks of discharge prevents hospital readmission. This presentation will describe the process used in the project and the preliminary findings of this approach to heart failure care. The preliminary results of the 18 patients enrolled in this on-going pilot project revealed no hospital readmissions or emergency room visits within 60 days post discharge. In addition, all patients with NYHA functional class IV status on hospital admission showed improvement or stabilization in NYHA functional status to I-II as well as improvement in their Minnesota Living with Heart Failure Scores. Based on these preliminary findings, a cardiovascular NP managed rapid access clinic can potentially prevent or reduce HF readmissions. It is an innovative outpatient care strategy that may help improve outcomes of patients discharged with HF.
N022 SUPPORTING REGISTERED NURSES TO FACILITATE ADVANCE CARE PLANNING (ACP) IN HEART FAILURE PATIENTS F Lau Toronto General Hospital, Toronto, ON
The illness trajectory of heart failure is characterized by periods of stability and acute exacerbations in which death becomes increasingly probable. As such, the Canadian
Abstracts
Cardiovascular Society’s Heart Failure Management Guideline (2011) strongly encourages heart failure patients to have advance care planning (ACP) or advance directives in place to improve quality patient-centered care. Research has demonstrated that clinicians often do not have adequate knowledge and skills to facilitate ACP. There is a need to address this identified gap, because literature indicated that some patients and families were ready to discuss ACP if clinicians initiated these conversations. The Registered Nurses Association of Ontario (RNAO) clinical fellowship provided an opportunity to advance clinical practice on developing knowledge and skills for facilitating ACP. During the fellowship, a four hours education session adapted from a communication skill training program was developed and presented to twelve Registered Nurses (RN) on the In-Patient Cardiology Unit. The session consists (a) didactic teaching on ACP and a communication theory; (b) identification of individual goals; (c) role-play in small groups and receipt of a pocket-sized communication cue card; (d) and development of personal goals for incorporating ACP in daily clinical practice. The pre and post-workshop evaluation showed that nurses’ self-reported confidence in facilitating ACP increased from 60% to 86%. Based on results of the evaluation, there is a potential for RN to increase ACP discussions at the actual clinical setting. Similar education session may be effective in other clinical areas to support RN in facilitating ACP conversations.
N023 TIME TO TALK...THE DEVELOPMENT AND IMPLEMENTATION OF A CARDIAC SURGERY HANDOVER TOOL D Schmidt,1 C Lazarenko,2 A Ferland2 1
Foothills Medical Centre, Calgary, AB
2
Alberta Health Services, Calgary, AB
Communication breakdown has been cited by healthcare safety experts as responsible for 75% of errors in healthcare. Studies have shown that clinical information important to physicians and nursing staff is often lost during patient transfer. Interdisciplinary handover between the Cardiovascular Intensive Care Unit (CVICU) and Step-down Unit 91(U91) at Foothills Medical Centre was not standardized. Inconsistencies and deficiencies were recognized anecdotally and through surveys in the handover of this patient information. An opportunity to create a clinical handover tool to optimize and standardize interdisciplinary communication was recognized. A working group was assembled to create a standardized clinical handover tool to be utilized in greater than 90% of patient handover between inter/intra disciplinary teams in CVICU and U91. The successful implementation of this tool resulted in a structured, retrievable, and easily accessible reporting system, where clinically relevant information is presented efficiently and succinctly. Over a period of twelve months, through multiple PLAN/ DO/STUDY/ACT cycles, a handover tool was created with
S321
the input of a multidisciplinary stakeholder group. Post implementation surveys and interviews demonstrate the handover tool has improved consistency of information transferred, reduced the incidence of missed information on transfer and increased awareness of the importance effective communication. Currently, 95% of patient transfers from CVICU to U91 are completed using the handover tool. Surveys completed by receiving staff demonstrate increased satisfaction with the transfer process, and an overall sense of increased confidence in patient care with the information received on the tool.
N024 YOUNG ADULTS COPING WITH A LEFT VENTRICULAR ASSIST DEVICE: A CASE STUDY T Morgan, S Gibson, A Bonaldo, A Storlarik, S Macdonald University of Ottawa Heart Institute, Ottawa, ON
For many young adults making the transition to adulthood can be challenging and stressful. This is a phase in life that is characterized by making career choices, leaving home and becoming independent from their parents, and possibly finding a partner. However, for a young adult living with a left ventricular assist device (LVAD) this phase of life is so much more complicated because a critical illness subverts this developmental process. The young adult is surrounded by equipment that cannot be ignored and is reminded constantly of the risk of death. The new normal is a life on standby, isolation from peer groups, limitations in activity and feeling confined, lack of privacy, living with anticipatory fear and dependence on others for support. Goals for the future are put on hold and independence is a dream. Hospitalization, frequent medical appointments, medications and technology are the new reality for this patient group. Through the use of a case study, this presentation will describe the successful, complex and innovative nursing strategies that were implemented to help the young adult patient cope with living with a device.
N025 END-OF-LIFE CARE IN HEART FAILURE PATIENTS WITH IMPLANTABLE CARDIOVERTER DEFIBRILLATOR: AN INTERDISCIPLINARY APPROACH B Gregorio, L Gallagher Southlake Regional Health Centre, Newmarket, ON
According to the Public Health Agency of Canada (2012) heart failure (HF) affects more than 485,000 Canadians. The Canadian Cardiovascular Society Guidelines for HF management (2014) incorporate device therapies for the prevention of sudden cardiac death and/or improvement of HF symptoms. However, research has shown that in the last weeks of their lives, 20% of patients with implantable cardioverter defibrillators (ICDs) receive shocks that are painful and