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

Michele Nakahara-Melo,Ana Paula Da Conceição,Diná De Almeida Lopes Monteiro Da Cruz Cruz,Vilanice Alves De Araújo Püschel

doi:10.1590/0034-7167-2021-0123

Michele Nakahara-Melo, Ana Paula Da Conceição + Show 2 more

Open Access

https://doi.org/10.1590/0034-7167-2021-0123

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Abstract

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. 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. 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. 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.

Highlights

METHODSWorldwide, heart failure (HF) is considered a pandemic that affects more than 64 million people[1,2]
This was structured by the researchers of the project in order to free the speech of the participants about the transition from the hospital to the home and in order to compile the most relevant subjects during this period: signs and symptoms of decompensation and/or side effects of the prescribed drugs, adherence to pharmacological treatment, reinforcement of self-care actions and the importance of attending the return visit to the clinic
It is worth mentioning that, during the telephone contact period, which varied from 21 to 28 days after discharge, only one patient reported having been hospitalized for 7 days due to hypotension due to HF decompensation

Summary

Introduction

Heart failure (HF) is considered a pandemic that affects more than 64 million people[1,2]. It presents diversified symptoms, and daily self-care actions for the control, monitoring and management of symptoms are essential[3]. Hospitalization due to HF decompensation is a predictor of poor prognosis, since about 25% of people in this situation die, and 40% are readmitted for at least one more time in one year[4]. In people with HF, TC involves several interventions to continue treatment in order to reduce and/ or prevent hospitalizations, providing follow-up in different contexts of health care, such as home and outpatient care[6]

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