Kelly D. Stamp, PhD, APRN, ANP-C Assistant Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts. Monique A. Machado, RN, MSN, ANP-BC Adult Nurse Practitioner, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts. Nancy A. Allen, PhD, ANP-BC Assistant Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.
J Cardiovasc Nurs. 2014 Mar-Apr;29(2):140-54. doi: 10.1097/JCN.0b013e31827db560.
Individuals with heart failure are frequently rehospitalized owing to a lack of knowledge concerning how to perform their self-care and when to inform their healthcare provider of worsening symptoms. Because there are an overwhelming number of hospital readmissions for individuals with heart failure, efforts are underway to discover how they can be supported and educated during their hospitalization and subsequently followed by a nurse after discharge for continued education and support.
The purpose of this integrative review was to critically examine the interventions, quality of life, and readmission rates of individuals with heart failure who are enrolled in a transitional care program. The second aim was to examine the cost-effectiveness of nurse-led transitional care programs.
The results of this integrative review (n = 20) showed that transitional care programs for individuals with heart failure can increase a patient's quality of life and decrease the number of readmissions and the overall cost of care. The types of interventions that were most successful in decreasing readmissions used home visits alone or in combination with telephone calls. There is a need for nurse researchers to address gaps in transitional care for heart failure patients by performing studies with larger randomized clinical trials and measuring outcomes such as readmissions at regular intervals over the study period.
The Patient Protection and Affordable Care Act will change reimbursement for heart failure readmissions and presents opportunities for healthcare teams to build transitional care programs for patients with conditions such as heart failure. This integrative review can be used to determine effective intervention strategies for transitional care programs and highlights the gaps in research. Healthcare teams that use these programs within their practice may increase continuity of care and quality of life and decrease readmissions and healthcare costs for individuals with heart failure.
由于心力衰竭患者缺乏自我护理知识，以及何时告知医疗保健提供者症状恶化，他们经常因缺乏知识而再次住院。由于心力衰竭患者的住院人数过多，因此正在努力寻找如何在住院期间为他们提供支持和教育，并在出院后由护士进行继续教育和支持。
本次综合回顾的目的是批判性地检查参加过渡护理计划的心力衰竭患者的干预措施、生活质量和再入院率。第二个目的是检查护士主导的过渡护理计划的成本效益。
本次综合回顾（n=20）的结果表明，心力衰竭患者的过渡护理计划可以提高患者的生活质量，减少再入院次数和整体护理成本。最成功减少再入院的干预措施是单独进行家庭访视或与电话访视相结合。护理研究人员需要通过进行更大规模的随机临床试验并测量研究期间定期的再入院等结果来解决心力衰竭患者过渡护理方面的差距。
《患者保护与平价医疗法案》将改变心力衰竭再入院的报销方式，并为医疗保健团队为心力衰竭等疾病患者建立过渡护理计划提供机会。本综合综述可用于确定过渡护理计划的有效干预策略，并突出研究中的差距。在实践中使用这些计划的医疗保健团队可以提高连续性护理和生活质量，并减少心力衰竭患者的再入院和医疗费用。
