2012 Preventive Cardiovascular Nurses Association Annual Symposium Accepted Poster Abstracts
Nearly 30 poster presentations were submitted for the Preventive Cardiovascular Nurses Association's 18th Annual Poster Session at the Annual Symposium in Washington, DC, from April 12 to 14. Accepted abstract authors were invited to submit a poster for presentation at the 2012 Preventive Cardiovascular Nurses Association 18th Annual Symposium, April 12 to 14, in the Washington, DC, metro area. There were two categories for poster presentations, including Data-Based Research for presentation of original research findings and Innovation in Patient Care for presentation of creative projects/programs in patient care.
Listed below are the accepted abstracts. Winners and oral presentations are published in the July/August issue of the Journal of Cardiovascular Nursing.
Category: Data-Based Research
Cognitive Function and Medication Self-management Errors in Older Adults Discharged Home From a Community Hospital
Debra Hain, PhD, APRN, GNP-BC1, Ruth Tappen, EdD, RN, FAAN1; Sanya Diaz, MD2; Joseph Ouslander, MD, 1Christine E. Lynn College of Nursing and 2Charles E. Schmidt College of Medicine, Florida Atlantic University, Ft Lauderdale.
Background: Correct self-management of medications is dependent upon the individual's ability to carry out a complex task, which involves intact cognitive function. This may be challenging when an older adult is discharged home after a hospitalization. Cognitive impairment whether temporary or irreversible can affect the person's ability to successfully manage medication. There is little evidence exploring the relationship between cognitive impairment and medication self-management post hospitalization.
Objectives: The purpose of this pilot project was to explore the relationship between cognitive function and medication self-management errors in older adults discharged home from a community hospital.
Methods/Design: This project utilized data from the second phase of a quality improvement initiative that had an overall purpose of reducing the risk of rehospitalizations in older adults (>=75) discharged home after an acute hospitalization. Participants were recruited from a 400-bed community hospital over a 5-month period of time. University IRB approval was obtained before data collection was started. Within 72 hours of discharge, participants were interviewed via a phone call and within one week of discharge, they received a home health visit from a RN. Medication discrepancies (Medication Discrepancy Tool), knowledge about medications (Discharge Knowledge Tool), and cognitive function (Mini-Cog) were assessed.
Results: One-hundred three older adults agreed to participant in both the phone call and the home visit. All were European American with a mean age of 83.2 years, and the most common index admission diagnoses were related to cardiovascular disease (34%), digestive problems (28%), or infection (18%). During the telephone call, about 87% stated they had no problems with medications; however, about 50% had one or more medication discrepancy noted during the home visit, and the most common medication error was related to cardiovascular medications. The findings support a relationship between cognitive function and medication discrepancies; 68% of those with cognitive impairment had one or more medication discrepancies and 83% had incorrect knowledge about medications (p < 0.05).
Conclusion: Although there are limitations to this project, the findings indicate that older adults may be more vulnerable to medication errors after hospitalization. Cognitive impairment may be one of the contributing factors. Cardiovascular medications were the most common medication errors, which could lead to 30-day rehospitalization. Therefore, it is critical that nurses make every effort to assess cognitive function using valid and reliable instruments as they develop interventions to reduce the risk of 30-day rehospitalization.
CVD Risk in a Mexican Community of Chicago: Beliefs, Prevalence and Environment
Karen Larimer, PhD, APRN, Meg Gulanick, PhD, APRN, Diana Hackbarth, PhD, RN, Sue Penckofer, PhD, RN, Loyola University Chicago, Illinois.
Background: Cardiovascular disease (CVD) affects persons of all races and ethnicities. The number of persons of Mexican ethnicity has increased significantly in the United States and the Chicago area. Healthy People 2020 highlights personal, social, economic and environmental factors that influence health. Understanding how these factors affect an urban Mexican population is necessary before culturally appropriate risk reduction strategies are designed and implemented.
Objectives: To understand selected determinants of health and individual risk factors that may contribute to CVD in one Mexican community. Determinants studied included awareness and attitudes about CVD; access to healthcare; and access to healthy foods and usable parks.
Methods: The Healthy People model guided this study. Multiple methods were used as sources of data: church-based health screenings of Mexican adults (n = 106), interviews of community key informants (n = 15), database searches, as well as direct observation and participation in the community.
Results: Screening data revealed that 45% of the sample was overweight; an additional 38% was obese; 33% had elevated total-cholesterol; 52% had low HDL-cholesterol; 44% had elevated glucose, and 35% had pre-hypertension. Informants reported that atherogenic diets and lack of exercise are common among residents and that diabetes, not CVD, ranked as the top health concern. Informants believed that while physical facilities for healthcare were adequate, access to facilities was not. Review of key databases revealed availability of stores selling fresh produce and plenty of parks for exercise. Economics, language problems, lack of appreciation of heart disease risk, and limited use of area resources appeared to be the greatest factors contributing to CVD risk.
Conclusions: This study provided a snapshot of an urban Mexican community at risk for CVD. Increasing awareness of heart disease as a health problem and promoting use of low cost, culturally appropriate resources should be the target for future risk reduction efforts.
Effects of Early Initiation of Induced Therapeutic Hypothermia
Frank Castelblanco, RN, MSN, Mission Health, Asheville, North Carolina.
Background: Cardiac arrests are responsible for about 325,000 deaths annually in the United States (Heart Rhythm Foundation, 2010). The majority of these cardiac arrests occur outside the hospital setting, with a lackluster national survival rate of 8% (American Heart Association, 2010). The Bernard (2002) and HACA (2002) studies demonstrated that by initiating therapeutic hypothermia as a treatment modality for cardiac arrests, the survival rate could be as high as 49% and 55%, respectively. Therapeutic hypothermia can be initiated in many different settings.
Purpose: The purpose of the study is to compare the effect of initiation of therapeutic hypothermia by EMS personnel vs emergency room nurses vs ICU nurses on patient outcome as measured by the Glasgow Outcome Scale in cardiac arrest patients.
Methods: This will be a nonrandomized retrospective observational study that will measure various data elements, patient mortality, and neurological status upon discharge. The subjects will consist of a convenience sample from a Therapeutic Hypothermia database of patients admitted in the 2008-2010 calendar years. The Glasgow Outcome Scale will be utilized to measure the subjects' survival rate.
The mortality rate will be measured based upon the terms "Expired, Solace, or Hospice" under the discharge disposition in the database.
Results: This study utilized a convenience sample of 178 consecutive cardiac arrest patients admitted from 2008-2010 to an 800-bed hospital in Western North Carolina. Out of the overall sample, 57 patients had a favorable neurological outcome (32% overall survival rate). EMS initiated therapeutic hypothermia in 24 instances, with 7 patients surviving to discharge (29% survival rate). The Emergency Department initiated therapeutic hypothermia in 17 instances, with 8 patients surviving to discharge (47% survival rate). ICU nurses initiated therapeutic hypothermia in 137 instances, with 42 patients surviving to discharge (31% survival rate).
Implications: Study results reproduced previous findings demonstrating the efficacy of therapeutic hypothermia in the treatment of cardiac arrests. The results also indicate a possible advantage to the initiation of therapeutic hypothermia by emergency departments.
Risk Perception and Health-Promoting Behaviors in Persons Informed of a Coronary Artery Calcium Score
Jennie Johnson, RN, BC, BSN, PhD(c), Meg Gulanick, PhD, APRN, FAAN, Sue Penckofer, PhD, RN, and Joanne Kouba, PhD, RD, LDN, Niehoff School of Nursing, Loyola University, Chicago, Illinois.
Background: Cardiovascular disease (CVD) remains the leading cause of adult deaths because individuals continue to engage in behaviors that exacerbate CVD. New technologies such as coronary artery calcium (CAC) screening detect atherosclerosis before clinical disease is manifested. Awareness of an abnormal finding should enhance motivation for change.
Objective: To examine how awareness of a CAC score affects risk perception and health-promoting behaviors in persons at high risk for CVD.
Methods: This study used a descriptive prospective design. 174 high risk adults (3 or more major risk factors) were recruited at a radiology center offering CAC scans in a Chicago suburb. Baseline self-report surveys using the Perception of Risk of Heart Disease Scale (PRHDS) and the Health-Promoting Lifestyle Profile II (HPLP II) commenced immediately following a screening CAC scan but before results were known. Follow-up occurred 3 months later using mailed packets. Participants were compared across 5 CAC scoring groups.
Results: Participants' mean age was 58 years; 62% male, 89% Caucasian, and well-educated. Repeated measures ANOVA indicated that risk perception was not significantly changed over time or between groups, except for significant positive interaction in group with CAC scores of 101-400 (p = 0.004). Risk perception scores were significantly higher in the combined positive CAC group compared to the 0 CAC group (p = 0.045). Health-promoting behaviors increased in all groups over time (p < 0.001). Chi-square analysis indicated that risk reduction medication use increased in all groups, with significant increase in lipid and aspirin intake. Responses from open-ended questions added validity to quantitative findings.
Conclusions: Awareness of CAC score does impact risk perception for some at risk groups. Knowledge of ones' score did enhance motivation for behavior change. It is hoped that through improved understanding of the effect of CAC scoring on behavior change, nurses will be better able to assist patients to modify harmful behaviors during teachable moments.
A Culturally-Specific Health Coaching Program Is Effective for Decreasing Cardiovascular Risk in South Asians
Elena Flowers, RN, MS, MA, School of Nursing, University of California, San Francisco; Avantika Mathur, University of Waterloo, Waterloo, Ontario, Canada; Cesar Molina, MD, El Camino Hospital, Mountain View, California; Ashish Mathur, MS, Anita Sathe, MS, South Asian Heart Center, Mountain View, California.
Background: Health coaching is an effective strategy for improving cardiovascular disease (CVD) risk factors. Coaching interventions have primarily been studied in Caucasians, and the effectiveness in other ethnic groups is not known. Further, adaptation of coaching to include culturally-specific components has not been studied. Compared to other ethnic groups, South Asians have disproportionately higher risk for CVD, making screening and risk reduction of paramount importance. The South Asian Heart Center offers a culturally-specific coaching program aimed at decreasing CVD risk in South Asian-Americans.
Objectives: Our aim is to describe the coaching program and determine its effectiveness at improving behavioral and clinical risk factors for CVD in South Asian-Americans.
Methods: Demographic and behavioral variables were collected by telephone interview, laboratory measurements were obtained after 10-hour fast, and anthropometric measurements were performed by trained personnel. Participants received individualized risk assessment and behavioral recommendations from a Health Educator. Coaches contacted participants regularly to provide encouragement, troubleshoot challenges, and assess adherence.
Results: In the first five years of the program, 3,434 people underwent risk assessment, 3,352 were candidates for coaching, 2,854 indicated a desire to participate in coaching, 1,414 received coaching, and 1,096 completed coaching for at least one year. The number of participants meeting behavioral recommendations at baseline compared to completion of the program increased by 11% (daily fruit intake), 13% (daily vegetable intake), and 14% (weekly physical activity) (p < 0.05 for all). Mean total cholesterol decreased by 4%, LDL-c by 4%, triglycerides by 12%, and HDL-c increased by 5% (p < 0.05 for all). Waist circumference decreased by 3 inches and heart rate decreased by 12 beats per minute (p < 0.05 for all). There was no change in weight or blood pressure.
Conclusions: This culturally specific individualized coaching intervention successfully modified dietary and physical activity behaviors, with accompanying improvement in clinical risk factors.
Benefits of Database Use in Smoking Cessation Recruitment
Anne Burns, RN, BA, University of Illinois at Chicago.
Background: Smoking cessation remains an elusive goal. There is particular need for improvement in cessation rates amongst smokers with hypertension and obesity because of their high risk for cardiovascular events. Database analysis can identify these patients in a population. The purpose of this project was to evaluate the effectiveness of database driven recruitment on enrollment and completion rates in a smoking cessation program.
Method: In April of 2010 at a primary care clinic for uninsured, low income people, two months of unstructured recruitment had yielded five candidates for a seven week smoking cessation program. None enrolled when contacted. Then an analysis of the entire clinic population (2489) was done to identify patients who were overweight, smoking and hypertensive despite two or more anti-hypertensive medications using a MSACCESS program designed for studying risk status by diagnostic groups. Of total smokers identified N = 347, 205 were males and 145 females. Mean age was 49. When patients were contacted to attend, individual risk status was reviewed.
Outcomes: Of the 347 smokers, 167 had hypertension. 87 of these were still hypertensive despite two or more anti-hypertensive medications, and 55 were also overweight. This identified our high risk group. 26 patients were contacted. 12 declined and 14 registered which filled our first class. 11 started the class and 6 finished, meeting the Lung Association goals for completion in any socioeconomic group. Serendipitously a statistically significant and clinically important gender discrepancy in B/P (blood pressure) control rates was noted. Of hypertensive patients who were smokers, fewer female patients had B/P at goal (6%) than males (39%). X2 = 9.8, p = .01. Of those with BMI greater than 30, 73% were female and 27% male.
Conclusion: Identifying a high risk group with database analysis may be an effective recruitment strategy. In this case it also revealed a previously unrecognized gender pattern in risk distribution. These results warrant further study with larger numbers.
Awareness, Risk Perception, and Behavioural Intention in Patients With a Myocardial Infarction
Debbie ten Cate, RN, MSc, Lecturer, Hogeschool Utrecht, Institute for Nursing Studies, Utrecht, the Netherlands, and, during this investigation, Student, Clinical Health Sciences, Utrecht University, Utrecht, the Netherlands; Claudia J. Gamel, RN, PhD, Division Woman and Baby, University Medical Center Utrecht and Utrecht University, Utrecht, the Netherlands; Berna G.M. Sol, RN, PhD, Hogeschool Utrecht, Institute for Nursing Studies, and University of Applied Sciences, Utrecht, the Netherlands.
Background: There is limited research on the association of awareness and risk perception of cardiovascular risk factors with behavioural intention (BI) in lifestyle related cardiovascular risk factors such as smoking, overweight, physical inactivity, excessive use of alcohol and insufficient intake of fruit and vegetables. This association of all risk factors concurrently and in patients who had a myocardial infarction (MI) less than one month ago has not been investigated.
Objective: To describe the association of awareness and risk perception of cardiovascular risk factors with BI in aforementioned lifestyle related risk factors in patients with a MI after hospitalization and within one month after MI.
Methods: In a cross-sectional observational study, 31 patients who suffered a MI recently were included. Awareness, risk perception and BI were measured with a questionnaire. For data-analysis linear regression was used, by which BI was divided into: risk factor not present, low intention and high intention.
Results: The mean score for awareness was 3.9 +/- 1.5 (low awareness) and for risk perception -0.7 +/- 1.4 (risk perception somewhat below mean). The mean scores for BI in smoking were 5.7 +/- 2.1 (high BI), overweight 0.6 +/- 1.7 (mean BI), physical inactivity 3.7 +/- 0.6 (very high BI), excessive use of alcohol -2.4 +/- 0.9 (low BI) and insufficient intake of fruit and vegetables 6.1 +/- 0.9 (high BI).
The scores on awareness and risk perception were not significantly different in patients with low and high BI in smoking, overweight, physical inactivity and insufficient intake of fruit and vegetables and patients without these risk factors.
Conclusions: The study demonstrated that patients who suffered an MI within the last four weeks have a low awareness and risk perception of cardiovascular risk factors and this is not associated with BI in lifestyle related risk factors.
The Use of Carotid Media Thickness in Predicting ST Elevation Myocardial Infarction
Lori Neri, CRNP, CLS, FPCNA, Heart Care Group, Lansdale, Pennsylvania.
Aims: Compared to patients with non-ST elevation myocardial infarction, patients who present with ST elevation myocardial infarction (STEMI) frequently have few traditional risk factors. In the present study, we examined the utility of carotid intima media thickness assessment (CIMT) on refining cardiovascular risk prediction in these patients.
Hypothesis: Using a vascular age algorithm to re-define the Framingham risk score will lead to better assessment of cardiovascular risk in patients presenting with a first STEMI.
Methods: Patients (n = 26) who presented to our institution with a first STEMI and no history of prior diagnosis of coronary artery disease or equivalent (diabetes, peripheral or cerebrovascular disease) underwent CIMT assessment within 30 days of admission. Using a linear regression algorithm derived from the Atherosclerosis in Communities database, we defined a vascular age for each patient (defined as the chronologic age at which each patients CIMT would represent the 50th percentile). This vascular age was then used to re-calculate a vascular age-adjusted FRS. Standard and CIMT-adjusted FRS were compared.
Results: The mean CIMT-adjusted "vascular age" was significantly higher than the mean chronologic age for the cohort as a whole (52.8 yrs vs. 79.5 yrs, p < 0.001). CIMT-adjustment of FRS led to a significant increase in 10 yr risk assessment for the cohort as a whole (10.1% vs. 17.2%, p = 0.015). When calculated using chronologic age, 2/26 patients (7.7%) had high risk FRS 10 yr event rates (defined as event rate >20%) compared to 11/26 patients (42.3%) when calculated using CIMT-adjusted age (p = 0.018).
Conclusion: The use of CIMT to calculate FRS using a CIMT-adjusted "vascular age" in a STEMI population led to significant improvement in our ability to define high risk for CAD among this patient population. Given that STEMI patients represent a younger population with fewer traditional risk factors vs. other ACS patients, these data suggest that CIMT may be beneficial in identifying and modifying risk factors and behaviors of patients who are at risk of STEMI.
Risk Factors for Cardiovascular Disease in Patients With Type 2 Diabetes at Kenyatta National Hospital, Kenya
Samuel Kimani, BScN, MSc, Stephen Kainga, BScN, Margaret Chege, MPH, PhD, Miriam Wagoro, BScN, MScN, University of Nairobi, Nairobi, Kenya.
Background: Cardiovascular diseases are a major cause of mortality and morbidity worldwide. In a sub Saharan Africa cardiovascular and other metabolic diseases including diabetes are increasingly causing significant socio-economic and health burden. The increase has severely affected our health care systems already struggling with the burden of tropical and communicable diseases. Patients with diabetes are 2-4 times likely to develop cardiovascular disease and/or stroke. Although the risk factors for cardiovascular disease among type 2 diabetes may be known, there is inadequate information concerning diabetic patients attending Kenyatta National Hospital (KNH).
Objective: To determine risk for cardiovascular disease among patients with type 2 diabetes at KNH.
Methods: This was a cross-sectional study involving 147 participants diagnosed with type 2 diabetes. Participants were recruited consecutively after provision of written consent. The socio-demographics and relevant clinical data were obtained. Cardiovascular assessment, heart rate, blood pressures, lipid profile, and anthropometric parameters were obtained using standard clinical methods.
Results: Majority (63.3%) of the participants were hypertensive and suffered diabetes for more than 10 years. Additionally, they had higher (p < 0.05) total cholesterols; however, only 26.5% were on anti-lipidemia therapy. The use of angiotensin converting enzyme inhibitors was associated with reduced (P < 0.05) risk of hypertension. Further, a significant number (69.2%) of participants added salt to food regularly and exhibited significantly (p < 0.05) higher anthropometric parameters and psychological stress.
Conclusion: Our study underscores the role of diabetes, hyperlipidemia, psychological stress, higher anthropometric parameters and high dietary salt intake as risk factors for cardiovascular disease among diabetes. The risk factors among diabetes mirror the general population and the adoption of multi-factorial approach can mitigate their effects. The approach should include early detection, routine biochemical monitoring and aggressive treatment, nutritional adherence, lifestyle modification and follow-up care.
Aspirin Significantly Reduces the Severity of the Individual Symptoms of Flushing Associated With Niacin Extended-Release Therapy
Andrew Lewin, MD, National Research Institute, Los Angeles, California; Moti Kashyap, MD, Long Beach VA Medical Center, University of California, Irvine; Ping Jiang, MS, Wendy Everhart, PharmD, Kamlesh Thakker, PhD, Abbott, Abbott Park, Illinois.
Background: Niacin is effective lipid-modifying therapy for patients with dyslipidemia; however, niacin-induced flushing, characterized by cutaneous itching, redness, tingling, and/or warmth, reduces patient adherence and clinician's choice of therapy.
Objectives: To evaluate aspirin's effects on individual flushing symptoms when used with niacin extended-release (NER).
Design and Methods: This is a prespecified analysis of a randomized, double-blind, 5-week study in subjects with dyslipidemia. Subjects received immediate-release, non-enteric-coated aspirin (acetylsalicylic acid) 325 mg (N = 167) or placebo (N = 84) 30 minutes before NER, at a starting dose of 500 or 1000 mg; subjects were titrated to NER 2000 mg by week 3. Subjects recorded daily flushing symptoms with the Flushing Assessment Tool.
Results: Aspirin significantly reduced the overall maximum severity of each of the 4 flushing symptom components (Table) and resulted in fewer discontinuations (1.8% versus 9.4%, P = 0.007), compared with placebo. In the NER + aspirin group, most experienced none or mild symptoms of flushing.
Conclusions: Immediate-release aspirin 325 mg administered 30 minutes prior to niacin extended-release can reduce the severity of each flushing symptom, which may potentially improve tolerability and help increase adherence.
Educational Intervention Increases Activation and Utilization of the Medical Emergency Team Among Medical-Surgical Nurses
Cshanyse Allen, MSN, DNPc, RN, Robin Johns, PhD, RN, Georgia Health Sciences University, Augusta, Georgia.
Background: Despite many efforts to improve patient safety within the acute care setting, unplanned admissions to ICUs and unexpected deaths among patients on medical-surgical units continue to occur. Utilization of a Medical Emergency Team (MET), also known as a rapid response team, has been shown to reduce unexpected deaths by delivering cardiovascular nursing expertise to the patient bedside prior to cardiopulmonary arrest. Critical to the successful implementation of the MET, however, is a thorough understanding among bedside nurses regarding the activation and utilization of such a team.
Objective: To examine baseline knowledge and attitudes of medical-surgical nurses regarding the use of the MET and to determine the impact of an educational intervention on the level of knowledge of the nurses concerning the team.
Methods: Guided by Donabedian's Structure-Process-Outcome model, an educational intervention was designed and implemented to determine if it would affect a change in knowledge among bedside medical-surgical nurses and empower them with the ability to successfully activate the MET. Quantitative data for this pilot project were collected using a pre-test/post-test design. Participants included 53 nurses on two medical-surgical units at a large regional medical center.
Results: Pre/post-test data analyses were conducted using paired t-tests. The post-intervention mean score (8.34, SD 0.97) was found to be significantly higher (p = 0.0001) when compared to the pretest score (6.1, SD 1.24). In addition, post-intervention activation of the MET significantly increased from a total of 3 MET calls pre-intervention to 11 MET calls post-intervention (p = 0.003) on the two pilot units over the study period.
Conclusions: Significant gains in knowledge level and improvements in activation of the MET occurred following the implementation of an educational intervention designed for medical-surgical nurses. These findings demonstrate the importance of providing medical-surgical nurses with proper education regarding the utilization of the MET.
Category: Innovation in Patient Care
Optimizing Care of Young Adults With Congenital Heart Disease
Sonia Valdez, RN, BSN, PHN, CVRN, St Joseph Hospital, Orange, California.
Background: Despite increasing survival for adults with congenital heart disease (CHD), little is known about ambulatory care and hospitalization experiences for young adults with CHD and their families. With CHD complications, young adults who previously received care through pediatric services may find themselves cared for by practitioners who only see adults. In 2005, there was no systematic approach to care of these young adults with CHD at St. Joseph Hospital, either in ambulatory care of the hospital. A nurse coordinator, hired for the Heart Institute, now oversees care of adult CHD patients. An informal needs assessment indicated that developmental needs of young adults were not being met.
Objectives: Identify and meet the needs of these young adults, provide a certified congenital heart program with specialist ready to care for this unique population.
Method: An algorithm was developed that delineates needs of young adults with CHD. Issues addressed are physical/medical and psychological needs of adults with CHD (eg, diabetes, liver disease, depression), patient-focused visits, coping strategies, changes in treatment regimens, and dealing with issues of adulthood such as sexuality, vocation, substance abuse, and insurability. The algorithm shows care delivery systems that will be used by the young adult, such as outpatient social services, counseling, support groups, case management, and ACHD clinical coordinator (facilitates referrals).
Evaluation: Successful patient transition to adult services is formally being evaluated using telephone follow ups, patient/family surveys, and staff evaluations.
Implications: Multidisciplinary staff use of this algorithm has been successful, with a smooth transition of these young adults with CHD from pediatric settings to adult ones. This has also enhanced job satisfaction from those caring for these patients.
Empowering Students to Facilitate Health Behavior Change Through an Advanced Practice Nursing Cardiometabolic Initiative
Jean K. Berry, PhD, APN, P. Melissa Hernandez, MA, University of Illinois at Chicago, College of Nursing.
Background/Purpose: Alarming increases in global obesity have doubled world rates in the last three decades. The United States ranks highest with obesity rates of 50% predicted by 2030. A deadly increase in type two diabetes has also occurred worldwide. With the dramatic escalation of these twin epidemics, there is an increase in government-sponsored initiatives in the United States addressing obesity and cardiometabolic diseases. One such initiative is our Advanced Practice Nursing (APN) Cardiometabolic Certificate Program.
Objectives: This program includes didactic courses and novel student activities. These activities target underserved populations with the highest incidence of obesity and diabetes. High schools, faith-based settings and a free clinic provided opportunities for development of students' teaching and management skills and volunteerism.
Design/Implementation:Pedometer walking programs: Targeting increasing physical activity, we began a "Fitness Boot Camp" walking program at a charter high school in the inner city, where 210 diverse students participated with competition between classes, as well as at our own College of Nursing. Winners of the charter school Fitness Boot Camp received prizes with recognition for their extraordinary efforts. Health screenings: Promoting self-management of cardiometabolic risks, health screenings were staffed by NP students and faculty. Held in Latino faith-based settings, screenings included blood pressure, blood glucose, lipid analysis, and BMI calculation. Free clinic: Managing type two diabetes, obesity and cardiometabolic problems, APN students applied new knowledge at a free clinic serving the underserved in the heart of an urban area. Critical management skills were utilized in a predominantly Latino population.
Outcomes: Our APN students screened over 250 adults, identifying obesity in 38% of this population, undiagnosed hypertension in 23%, and dyslipidemias in 90%. Students provided health counseling and written materials with recommendations for healthy lifestyles and referrals to providers when necessary. Over 500 people were served with these three novel student projects.
Prompting the Public to Risk Stratify Themselves for Heart Disease
Kelly Galler, MSN, GNP, Bellin Health System, Green Bay, Wisconsin.
Purpose: Bellin's vision: People in our region will be the healthiest in the nation. Heart disease is the number one killer but early treatment improves outcomes and decreases cost. Heart calcium scoring with computed tomography (CT) finds patients with sub-clinical atherosclerosis before any symptoms occur, since coronary calcification is virtually 100% specific for atherosclerosis and non-obstructive calcified plaque is predictive of coronary events. Risk factor modification begins earlier when disease is identified.
Implementation: A program for self-referral, low cost ($50) heart calcium screenings was designed. With standing orders, screening tools and a 320 slice CT scanner, qualified individuals receive minimal radiation. Within 24-48 hours, a radiologist reads the lungs fields and aorta, then cardiology performs the calcium scoring interpretation. A nurse practitioner explains results via phone to answer questions, offer risk factor counseling and make referrals. Patients and primary care providers (PCPs) receive written results in the mail.
Evaluation and Outcomes: Community demand continues to be high. Key to success are phone call results, with PCP or specialist follow-up. About 23% of 6,550 heart calcium screenings require follow-up exams for abnormal results such as a high calcium score (>400), lung nodules and ascending aortic aneurysms. Ancillary revenue produces about 1.2 million dollars per year and this does not include professional services.
Implication for Practice: A significant amount of early heart and lung disease is found with heart calcium screenings. Offering this service at a low price allows at risk individuals the opportunity to take charge of their health, prevent progression of disease and avoid hospitalizations. Calcium scoring is a powerful motivational tool that can improve patient compliance with risk factor modification. Expanding programs like this can impact health care dollars, improve the quality of life and decrease the volume of heart attacks, lung cancers, and aortic aneurysms resulting in death.
The Development and Implementation of a Thoracic Aneurysm Management Program
Andrea Storper, MSN, APN-C, Jason Sperling, MD, FACS, Valley Hospital, Ridgewood, New Jersey.
Background: Thoracic aortic dissection/rupture due to aneurysm is a medical emergency associated with substantial morbidity and a mortality rate estimated at 14 to 30%. While most patients are asymptomatic, advances in imaging technology have increased the incidental diagnosis of aneurysms. Prevention of aortic catastrophe is paramount in managing these patients.
Purpose: A Thoracic Aneurysm Management program was created to provide comprehensive evaluation, medical/surgical treatment, and education for patients presenting with any history of aortopathy. The goal is to reduce the incidence of catastrophic events through ongoing surveillance and patient education for risk factor reduction.
Implementation: The program was conceived and developed by one of the cardiothoracic surgeons. Patients referred for consultation meet with the surgeon, who uses a comprehensive risk stratification model. Relevant films and reports are reviewed. Based on presenting symptoms, size and location of the aneurysm and presence of valvular or coronary heart disease, patients are triaged to surveillance or surgery. All relevant data are recorded in a detailed database by a nurse practitioner. Surveillance includes imaging every 6 to 12 months based on risk factors and status, with a follow-up phone call interview by the nurse practitioner to discuss imaging results, relevant symptoms, existing co-morbidities, and activity restrictions. Risk factor modification is reinforced, and subsequent follow up is scheduled. Need for surgical intervention is assessed by the surgeon.
Outcomes: Since its inception, 250 patients have been enrolled in the surveillance program. Multiple cardiovascular risk factors are monitored, including HTN, overweight/obesity, abnormal lipids, and smoking.
Implications: While the goal of the Thoracic Aneurysm Management Program is to identify and follow up potentially life threatening aneurysms, the follow-up interview affords the nurse practitioner the opportunity to provide counseling regarding risk factors related not only to aneurysm progression, but also CHD development and progression.
Nationalizing PE and DVT Support Groups
Ruth Morrison, RN, BSN, CVN, Brigham & Women's Hospital, Winthrop, Massachusetts; Kathryn Mikkelsen, BS, Brigham & Women's Hospital, Boston, Massachusetts.
An estimated 900,000 people in the United States develop deep vein thrombosis (DVT) or pulmonary embolism (PE) each year. DVT and PE survivors face many unique challenges including lingering physical discomfort and limitations, anxiety, and uncertainty about the future. Blood clot survivors and their families need support and information to manage the effects of a blood clot and prevent reoccurrence. Studies have shown that patients who participate in support groups are less anxious, less depressed, and have more knowledge about their illness. In 1993 Samuel Z. Goldhaber, MD, and Ruth Morrsion, RN, BSN, CVN, started the Pulmonary Embolism Support Group at the Brigham and Women's Hospital in Boston, MA. The purpose of the group is to focus on the unmet emotional and educational needs of patients diagnosed with a PE or DVT. 18 years later, this support group is viable and serves as a role model for a program Nationalizing PE and DVT Support Groups. The specific objectives of this program are to: 1) increase the number of hospitals that adopt and maintain successful PE Support Groups, 2) cater to the unmet psychological needs of patients stricken with DVT and/or PE and their families, 3) foster patient education, awareness, and advocacy, 4) educate healthcare providers (HCPs) on communication skills that allow them to better counsel and educate patients in a support group setting, 5) develop a PE support group blog which will allow participating hospitals and support group members from around the United States and Canada to connect, 6) develop and employ a five-phase evaluation instrument that measures patient participation, learning, and whether psychological needs have been understood and met, 7) publish a document on how to successfully create and maintain a support group. We currently have several hospitals in the US and Canada starting PE support groups.
Development and Implementation of a Standard Congestive Heart Failure Education Guide and Evaluation of the Impact on Medical Therapy, Hospital Readmission Rates and Patient Outcomes
Patricia A. Geiger, RN, MSN, ANP-BC, DNP, Buffalo Cardiology and Pulmonary Associates, Boston, New York; Terry Darlak, RN, ANP-BC, Judy Griffin, RN, ANP-BC, Mary Kennedy, RN, MSN, CNS, ANP, Kaleida Health, Buffalo, New York.
Purpose: This project is designed to facilitate best practice care and improve outcomes for patients admitted to the Kaleida Health System in Buffalo, New York, with congestive heart failure during hospitalization and following discharge.
Project Design: A pilot sample of 100 patients ages >=50 years old admitted with a diagnosis of congestive heart failure or development of during hospitalizaion will be instructed in the hospital with a congestive heart failure education guide developed for the purpose of this study. The guide content will include education and the disease state and the use of evidence based best practice therapies.
Method: An observational longitudinal study was utilized to compare congestive heart failure patient evidence based medication usage and outcomes pre and post implementation of the education guide and education process. A group of 100 patients admitted within six months prior to initiation of the program will serve as the control group. Data will be obtained by chart review and analysis will consist of multivariate regression. Outpatient medication compliance data will be accessed through home care follow up data with the Visiting Nurses Association (VNA).
Outcome Measures: The major end points are hospital length of stay, in-patient and outpatient use of evidence based medications of beta blocker, angiotensin converting enzyme inhibitor, angiotensin receptor blocker, and diuretics, mortality, outpatient medication compliance and 30, 60 and 90 day readmission rates.
Conclusion: Recent literature supports the positive impact of education on improving congestive heart failure patient outcomes. The goal of this pilot project is to implement a formal education process in order to improve congestive heart failure patient outcomes in the Kaleida Health System.
Dyslipidemia Care Management: The Affect of Statin Medication Dosing Protocols and Therapeutic Lifestyle Changes in Patients With Coronary Artery Disease or Diabetes
Theodore A. Praxel, MD, FACP, MMM, Marilyn A. Follen, RN, MSN, Institute for Quality, Innovation & Patient Safety, Marshfield Clinic, Marshfield, Wisconsin; Kori Krueger, MD, Melissa Mikelson, RN, Debrah Johnson, RN, James Riedel, BA, Marshfield Clinic, Marshfield, Wisconsin.
Purpose: To reduce low-density lipoprotein (LDL) levels and promote wellness through therapeutic life style teaching by utilizing motivational interviewing and physician-approved statin medication protocols.
Design: The program is delivered telephonically by registered nurses (RN) certified in dyslipidemia care management and motivational interviewing. Patients are enrolled into a statin dosing care plan which includes therapeutic lifestyle changes (TLC) teaching and medication monitoring. Patients who refuse or cannot tolerate statin medications are enrolled into a therapeutic lifestyle change care plan which emphasizes TLC as primary treatment.
Outcomes: From October 2009 to September 2011, 342 patients were enrolled in the program. 27 patients were enrolled into the TLC Care Plan only. Co-morbidities in this population included congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, hypertension, diabetes mellitus, coronary artery disease.
Implications for Practice: The impact of nursing using motivational interviewing to promote disease self-management cannot be minimized. While statin medication titration resulted in improved LDL control, TLC changes impacted A1C and weight loss.
Does Health Coaching Improve Patient Engagement?
Lesa Abney, RN-BC, CPHC, Zack Klint, MS, Allison Jagoda, MS, Jeremy McNatt, MEd, Sherri Cedzich, BSN, RN, Vanderbilt University Medical Center, Nashville, Tennessee; Lisa Creekmur, BSN, RN, CPHC, Mt Juliet, Tennessee.
Background Summary: The Center for Disease Control projected the cost of treating heart disease in the United States to reach 316.4 billion in the year 2010. The challenge remains for cardiac rehab professionals: how to improve patient engagement and behavior change without increasing cost.
Purpose: To determine if adding health coaching improves patient engagement in a cardiac rehab setting.
Description of Innovation: Ten patients admitted with acute coronary syndrome were followed from point of admission to a 7th day visit and transitioned to an outpatient cardiac rehab facility. Patients received 36 visits of traditional cardiac rehab in addition to 6 health coach sessions (1 face to face visit: 60 min.; 5 telephonic visits: 30 min). Total cardiac rehab visits for the intervention group were compared to the number completed for the entire Vanderbilt University Medical Center cardiac rehab population.
Evaluation and Outcomes: The control group completed an average of 16.7 visits while the intervention group completed 22.9 visits of cardiac rehab. These data represent an increase of 37%, indicating improved patient engagement.
Implication for Practice: Health coaching can be adapted to multiple settings, including face to face and telephonic visits. The greatest impact may be the ability to use telephonic coaching to improve patient engagement for individuals living over 50 minutes away commonly seen in tertiary hospital settings.