Case Study: Daily Review of Telemonitoring Data by a Critical Care Nurse Improves Outcomes in a Patient with Class IV, Stage D Heart Failure with Reduced Ejection Fraction Receiving Home Intravenous Dobutamine for Palliation.

Abstract

Purpose The purpose of this case study is to demonstrate how a robust telemonitoring program, which includes daily critical care nurse review of heart failure symptoms, vital signs, oxygen saturation, weight, and blood glucose levels, prompts clinical interventions that result in overall improved symptom management and decreased hospital readmissions for a patient requiring home inotrope infusion. Objectives 1. To summarize particular telemonitoring data that triggered nursing telephonic outreach for further patient evaluation 2. To summarize clinical interventions resulting from data and nursing telephonic outreach 3. To report patient outcomes (symptom improvement and avoidance of hospitalizations) Methods A retrospective review of this patient's medical record was performed, which consisted of telemonitoring data, physician order changes, and clinical assessments performed by critical care nurses. Results This 50-year-old male with Class IV, Stage D heart failure with reduced ejection fraction was admitted to this home infusion provider on 03/26/2015 to receive palliative treatment with continuous intravenous dobutamine 2.5 mcg/kg/min and daily telemonitoring. He was not a candidate for advanced heart failure therapies, such as left ventricular assist device or heart transplant, due to prior noncompliance with his treatment plan. The first telemonitoring data was transmitted on 03/28/2015. The patient was largely compliant with daily data transmissions throughout the course of care, which ended 06/03/2015 when the patient's insurance changed and the payor mandated transfer of care to another home infusion provider. A telephonic assessment performed by a critical care nurse occurred each day the transmitted data triggered an alert. A total of 25 alerts were received and are summarized as follows: 1 increased lower extremity edema, 5 weight increased more than 2 pounds in 24 hours, 7 heart rate and blood pressure elevations, 2 blood glucose elevations, 1 increased orthopnea, 1 significant weight loss in 24 hours, and 8 missing daily data transmissions. These alerts and resulting telephonic assessments prompted 61 clinical interventions, which included: 32 nursing visits for IV furosemide administration, 7 patient education sessions, 1 additional dose of oral furosemide, 7 rechecks of blood pressure and heart rate, 6 physician contacts, and 8 patient contacts requesting health check/data transmission. Conclusions Daily critical care nurse telemonitoring resulted in nearly daily interventions with gradual stabilization of weight and vital signs, no decline in respiratory status, and no hospitalizations throughout 69 days of service. Of particular significance is the fact that telemonitoring improved the patient's compliance to his treatment plan, which resulted in an evaluation for a left ventricular assist device placement. Results