Walden Dissertations and Doctoral Studies
Steps to Reducing Heart Failure Hospital
Readmissions Through Improvement in
Paticia Laubach Dunn
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College of Health Sciences
This is to certify that the doctoral study by
has been found to be complete and satisfactory in all respects,
and that any and all revisions required by
the review committee have been made.
Dr. Catherine Harris, Committee Chairperson, Health Services Faculty
Dr. Robert McWhirt, Committee Member, Health Services Faculty
Dr. Oscar Lee, University Reviewer, Health Services Faculty
Chief Academic Officer
Eric Riedel, Ph.D.
Steps to Reducing Heart Failure Hospital Readmissions
Through Improvement in Outpatient Care
MSN, ARNP, University of Central Florida, 1999
Project Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
The outpatient care of the heart failure (HF) patient is fragmented due to lack of
evidence-based practice guidelines use. The primary goal of this project was to improve
the care of the HF patient in the outpatient arena through use of clinical pathways using
the logic model as the project framework. The intervention was carried out over a 4-week
period on a convenience, random sample of patients (n = 80) attending a cardiology
practice. The patients were recruited from 2 physiciansâ€™ patient populations and selected
based on an adult diagnosis of HF, reduced ejection fraction of <40% at some point in
time, and a New York Heart Association (NYHA) functional class II-V. Comparisons
were made in the documentation of care between patients on or off the pathway. The
intervention included documentation of patient education, care follow-up, medications,
NYHA class, and symptom exacerbation, documented in the electronic medical record.
The quality of care data were evaluated based on 3 of the Joint Commission core
measures for outpatient care of the HF patient. Additional data were collected regarding
use of the clinical pathway based on provider and week of implementation. Data were
analyzed via a Chi-square test of independence comparing pathway use by provider and
use of pathway as study progressed. The comparative results show statistically significant
differences in use of the pathway by provider and a statistically significant increase in use
during the project. The quality of care results varied in statistical significance. The
pathway utilization increased over time and provided a method for standardizing
documentation of care for the HF patient in this outpatient clinic, a benefit for HF
patients and providers in this cardiology practice and beyond.
Steps to Reducing
Heart Failure Hospital Readmissions
Through Improvement in Outpatient Care
MSN, ARNP, University of Central Florida, 1999
Project Submitted in Partial Fulfillment of the
Requirements for the Degree of
Doctor of Nursing Practice
I would like to thank the faculty at the Walden University School of Nursing for
providing the opportunity for an excellent educational growth experience. I would
especially thank Dr. Catherine Harris, PhD for her exceptional patience, mentoring, and
responsiveness throughout this project. I would also extend my appreciation to Dr. Robert
McWhirt, DNP for his positive encouragement and to the university research reviewer,
Dr. Oscar Lee for his assistance in this process. I am extremely grateful to Dr. Nancy
Johnson, MD, FACC, FAHA for her clinical mentorship and support, which was so
valuable to me throughout this program and project.
Lastly, I thank my loving husband Keith and daughter Kelsie for their patience,
tolerance, and sacrifice in order to help me pursue this goal. Without their continued
support and encouragement, completion of this endeavor may not have been possible.
Table of Contents
List of Tablesâ€¦â€¦â€¦â€¦â€¦â€¦â€¦ â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦…v
List of Figure………………………………………………………………………………………………………. vi
Chapter 1: Overview of Heart Failure …….â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦..1
Explanation of Problem …………………………………………………………………………………….1
Problem Statement ……………………………………………………………………………………………2
Significance of Heart Failure ……………………………………………………………………………..2
Context and Magnitude ………………………………………………………………………………..3
Needs Assessment ……………………………………………………………………………………….5
Research Question and Hypotheses …………………………………………………………………….7
Research Question ……………………………………………………………………………………..7
Purpose and Objective ………………………………………………………………………………………8
Treatment and Adherence ………………………………………………………………………………….9
Definition of Terms…………………………………………………………………………………….12
Chapter 2: Review of the Scholarly Evidence …………………………………………………………15
Inpatient Care …………………………………………………………………………………………………16
Outpatient HF Care ………………………………………………………………………………………….18
Palliative Care ……………………………………………………………………………………………….. 20
Treatment Guidelines ……………………………………………………………………………………….23
Conceptual Model ……………………………………………………………………………………………29
Chapter 3: Approachâ€¦ ……….â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦31
Population and Sampling …………………………………………………………………………………34
Data Collection ………………………………………………………………………………………………34
Protection of Subjects ………………………………………………………………………………. 35
Evaluation Plan ……………………………………………………………………………………………….36
Chapter 4: Project Results and Implications …………………………………………………………….39
Summary of Findings ………………………………………………………………………………………41
Correlation Data Outcomes……………………………………………………………………………….43
Pathway Utilization ……………………………………………………………………………………43
Pathway Utilization by Provider ………………………………………………………………….44
Pathway Utilization by Week ……………………………………………………………………..45
Findings in Context of HF Care …………………………………………………………………………46
For Practice Change …………………………………………………………………………………..49
For System Change ……………………………………………………………………………………51
For Future Research …………………………………………………………………………………..52
Project Strengths and Limitations ………………………………………………………………………54
Recommendations for Reduction of Limitations ……………………………………………55
Analysis of Self ………………………………………………………………………………………………56
Evaluation of Scholarly Growth …………………………………………………………………..56
Evaluation of Practitioner Growth ………………………………………………………………..56
Evaluation as Project Developer …………………………………………………………………..57
Future Professional Development Related to HF Project …………………………………58
Chapter 5: Program Evaluation Report ……………………………………………………………………61
Project Goals …………………………………………………………………………………………………..62
Project Outcomes …………………………………………………………………………………………….62
Areas of Further Study ……………………………………………………………………………………..64
Plans for Dissemination ……………………………………………………………………………………66
Appendix A: Heart Failure Logic Model …………………………………………………………………77
Appendix B: Project Timeline ……………………………………………………………………………….78
Appendix C: Heart Failure EMR Flow Sheet …………………………………………………………..79
Appendix D: Pathways …………………………………………………………………………………………80
Curriculum Vitaeâ€¦ ………………………………………..â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦84
List of Tables
Table 1. Frequency Data on Pathway Utilization and Variablesâ€¦â€¦ …â€¦â€¦â€¦â€¦â€¦â€¦â€¦42
Table 2. Pathway Utilization by Provider ……………………………………………………………….45
Table 3. Pathway Utilization by Week of Implementationâ€¦..â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦â€¦..46
List of Figures
Figure1. Call Back Patient Questionnaire ………………………………………………………………. 43
Chapter 1: Overview of Heart Failure
Heart disease is the leading cause of death in the United States and a potential
precipitating factor for heart failure (HF). HF is the term given for the heartâ€™s inability to
sufficiently pump the blood through the body. Left-sided HF is a symptom of failure or
decreased function of the left ventricle and is primarily caused by coronary artery disease
(CAD) or uncontrolled hypertension (HTN); however, cardiomyopathy, which is an
enlarged or thickened left ventricle, can also cause left HF (Markaity, 2012). Right-sided
HF is caused by increased lung pressure, which is typically secondary to pulmonary
hypertension, chronic obstructive pulmonary disease, pulmonary valve stenosis, or
frequent pulmonary blood clots (Markaity, 2012). HF is a frequent cause of hospital
admissions in the United States, with the risk for repeat hospitalizations being high.
Explanation of the Problem
The Center for Medicare and Medicaid Services (CMS) places a priority on
reducing the number of hospital readmissions within 30 days for high-risk diagnoses such
as HF, ultimately financially penalizing hospitals with unacceptable rates (Center for
Medicare and Medicaid Services, 2011). Readmissions of patients with HF cause an
increased financial burden to the system and can be a predictor of adverse patient
outcomes. Hospitals may face financial penalties on Medicare reimbursement and valuebased purchasing incentives if 30-day readmissions of HF patients are above recognized
Improvement in in-patient hospital care, use of evidence-based practice (EBP)
guidelines, guideline-directed medical therapy (GDMT), readiness assessment for
discharge, and transition of care to outpatient status are encouraged to optimize outcomes
and reduce the frequency of hospital admissions or readmissions for HF. (U.S.
Department of Health & Human Services, 2013). This process, however, is not always
A problem exists with the continued care of the HF patient after stabilization and
hospital discharge. Data have shown that care of the HF patient is frequently fragmented
and hospital readmissions may be prevented with more structured follow up care (Kay et
al., 2006). While much literature is available regarding in-patient HF care and outcome
monitoring, and there has been an increase in literature available guiding the structure
and development of formal outpatient HF clinics, little literature is found to guide the
independent practice in the effort to provide and monitor adequate care to the HF patient
in a structured manner.
Significance of Heart Failure
In 2009 approximately 5.7 million Americans had a diagnosis of HF. It was a
contributing factor in 280,000 mortalities in 2008 alone and the incidence is increasing,
with 650,000 new cases diagnosed each year (Center for Disease Control and Prevention,
2013). It is estimated that half of the people diagnosed with HF will die within 5 years of
diagnosis, with a cost to the healthcare system of approximately 34 million dollars
annually, including the cost of treatment and disability losses (Center for Disease Control
and Prevention, 2013). HF is the cause of 12-15 million office visits and 6.5 million
hospital days annually, with the prevalence rising as the elderly population increases with
the aging of 78 million baby boomers. One in five Americans are expected to be over the
age of 65 by 2050 (Butler, 2012).
The county in Florida in which this study was conducted, had a population of
545,750 in 2011, with 2,522 annual hospitalizations for coronary heart disease (CHD)and
541 hospitalizations for congestive heart failure (CHF), representing an age-adjusted rate
of 309.1 and 72.2 per 100,000 respectively, according to the county chronic disease
profile (Florida Department of Health, 2013). The annual death count in this county from
CHD in 2011 was 992; it was 74 for HF. The age-adjusted death rate from HF in Florida
and this county has been on the increase, with higher rates of HF occurring among men
specifically Black men (Florida Department of Health, 2013).
HF can affect adults of all ages but it is a significant problem and a major cause of
hospitalizations in patients greater than 65 years old and carries a high mortality rate
among elderly (Mant, Al-Mohammad, Swan, & Laramee, 2011). The incidence of HF is
increasing and is more prevalent in those over 65; therefore, as the population ages so
does the risk for developing HF ( Pinkerman et al., 2013), however, of the 541 HF
hospital admissions in 2011, in the county in which this study was conducted, 415 of
them occurred in those under age 65 and were categorized as preventable (Florida
Department of Health, 2013).
Context and Magnitude
In Florida alone, the age-adjusted death rate from HF has increased from 1,605 in
2003 to 2,418 in 2011; which is a rate increase from 6.9 to 8.9 per 100,00 (Florida
Department of Health, 2013). According to the Florida-US Health State comparison
ranking in 2009 (Florida Department of Health, 2013), the age-adjusted diagnosis of HF
in Florida was 244.1 per 100,000, compared with the U.S. statistic of 158.9 per 100,000,
although deaths from HF are lower at 7.7 compared to 16.9 respectively.HF is a condition
composed of signs and symptoms and often difficult to classify as a specific cause of
death; therefore, limitations calculating the exact mortality rates exist because of potential
misclassification of, or failure to list as, a cause of death (National Institutes of Health,
The calculated 30-day national risk-standardized readmission rate (RSRR)
for HF in 2007-2009 was 24.7% (Center for Medicare and Medicaid Services, 2011).
Recent statistics from a local for-profit hospital in Central Florida showed a 30-day
readmission rate for HF patients of 28%, which placed this hospital at risk for Medicare
reimbursement penalties. While this hospital has been successful in reducing the
readmission of HF patients over 9 months from 28% to 11% through hospital process
changes, there is uncertainty if these improvements will be maintained without a formal
outpatient follow-up care guidance plan. The patients from this hospital are discharged to
individual cardiologists, internists, and primary care providers for follow-up care with the
expectation that standardized EBP guidelines will be utilized in follow-up care.
Reduction in HF readmissions starts with in-patient care through development and
implementation of multidisciplinary pathways, which include proper use of medications,
life-style and risk factor modification, and patient education based on EBP guidelines,
optimally followed by appropriate outpatient care (Herrick, 2001). Outpatient HF clinics,
which specialize in the care of HF patients, have shown improvement in patient quality of
life and management of patient symptoms, in part through use of evidence-based
guidelines for care management, but also through patient and family education and close
patient follow up (Kutzleb & Reiner, 2006).
The for-profit hospital system serves community healthcare needs; however, the
focus also is placed on positive financial returns that can be distributed among
shareholders. Often for-profit hospitals achieve financial gains by limiting unprofitable
services and offering those that generate revenue or are profitable (Horwitz, 2005). Even
though HF disease management clinics have shown a positive return on investment (ROI)
in some cases, projecting profits and expenses and developing a business plan could be
difficult. The question remains if they are financially feasible and cost effective in a forprofit healthcare system whose emphasis is on the financial bottom line and ROI
(Goetzel, Ozminkowski, Villagra, & Duffy, 2005).
Guidelines and recommendations for the care of the HF patient are well
established and documented in the literature and include recommendations for medical
therapy, lifestyle changes, hospital follow up and ongoing monitoring, and palliative care
(American College of Cardiology Foundation/American Heart Association, 2013;
Lainscak, 2004; Mant, Al-Mohammad, Swan, & Laramee, 2011; National Clinical
Guideline Cemtre, 2010; Whitlock, 2010). Despite these guidelines and recommendations
that are widely available to providers, HF hospitalizations remain high; therefore, in order
to prevent symptom exacerbation, hospitalizations, and re-hospitalizations, a clear
recognition of care deficiency areas and patient care needs should be established.
Involving the direct care provider as a primary stakeholder in the needs assessment can
help reveal deficiencies.
The normative need of the HF patient for this project was established using
secondary sources for data collection, including Florida Department of Health, Division
of Public Health Statistics & Performance Management, CDC, and Florida Charts county
and state profile reports to assess the prevalence, morbidity, and mortality of HF in the
chosen community compaired to state and federal statistics. Perceived need was
established by relying on key informant interviews from members of the healthcare team
caring for HF patients and through primary and secondary data sources, including
members of nursing services, medical providers, case-mangement, and home-care
providers. These individuals are considered primary stakeholders in this project and
helped to elucidate areas of deficiency in local HF care answering questions such as
perception of care deficits, number of patients hospitalized monthly with HF, frequency
of homecare follow up, and number of patients receiving standard evidence-based
therapies through review of discharge and admission data. Expressed need was
established by review of the literature, data collection on inpatient care and outpatient
follow up care, and utilizing services such as homecare, telemedicine data, cardiac
rehabilitation services, expert opinion, patient data, and secondary sources such as chart
reviews and available service statistics.
The common threads of needs to improve HF care and prevent readmissions were
identified as stakeholder involvement, consistency of care, appropriate use of evidencebased therapies, timely follow up post hospital discharge, patient adherence to prescribed
medications and diet promoted through patient and caregiver education, and patient
understanding of symptoms of disease progression with timely reporting. After these
needs were reviewed, the research question was developed.
Research Questions and Hypothesis
Efforts to improve the care of the HF patient should continue beyond
hospitalization. These efforts should include optimizing the care provided at the
outpatient clinic. In the heart failure patient, can the outpatient care process be improved
at a for-profit health system?
To answer this question several processes of care for the HF patients in an
outpatient cardiology clinic were analyzed. These processes were related to utilization of
recommended GDMT and development and utilization of a HF clinical care pathway,
which led to the first null hypothesis that there was no difference in care for patients
utilizing the heart failure pathway.
Providers may react differently to the utilizing clinical pathways and clinical
guidelines. This difference has been demonstrated by documented fragmentation and
inconsistency of care despite the existence of well-established guidelines (Fonarow et al.,
2008). Questions related to the potential difference in pathway utilization by providers
led to the second null hypothesis that there would be no statistical difference between
provider and pathway utilization.
Changing practices and behaviors may take time. Changes to the status quo and
challenges to perceived authority or knowledge are not always well received, with
cultural barriers frequently being the most formidable roadblock to change (Best &
Neuhauser, 2006). Recognizing these change barriers led to questions related to
acceptance of the pathway over time and the third null hypothesis that there would be no
difference in pathway utilization based on the week of the study.
Purpose and Objective
The purpose of this project was to improve the care of the HF patient in the
outpatient cardiology clinic associated with a for-profit health system by utilizing an
evidence-based guided HF clinical pathway for care coordination, with an objective to
improve the care process. This project was done with the objective of laying the
foundation for a nurse-led HF clinic, promoting multidisciplinary team collaboration, and
instituting practice change to promote standardized, continuity of care, and consistency of
care including timely follow up, utilization of EBP guidelines and guideline-directed
medical therapy, and education to increase patient self-care through patient adherence to
diet, lifestyle, and follow-up recommendations, as well as to increase the patientâ€™s
understanding of signs and symptoms of disease progression, thereby improving patient
outcomes and quality of life.
Changes to the status quo and challenges to perceived authority, knowledge, or
established patterns and habits are not always well received, with cultural barriers
frequently being the most formidable roadblock to change (Best & Neuhauser, 2006).
The challenge to support the patients and providers while encouraging guideline
implementation and practice change is an obstacle that can be approached with change
theory. The framework for this project was chosen to support the process rather than
specifically to apply to a disease management program. The theory of reasoned action
(TRA)/ theory of planned behavior (TBA) links peopleâ€™s behaviors to beliefs, attitudes,
and intentions and has been used extensively in health research to predict health
behaviors (Evans, Ndetan, & Williams, 2009). This theory was used as a framework to
support the planned process change to improve practice and care for this patient group.
Literature supports use of TRA/TBA for understanding and motivating behavior change
in providers and patients (Bilic, 2005; Courneya, K. S.; Rodgers, W. M.; Fraser, S. N.;
Murray, T. C.; Dub, B.; Black, B., 2003; Evans, Ndetan, &Williams, 2009).
Treatment and Adherence
The interventions for treatment of HF include, but are not limited to, the
prescribed use of multiple medications based on evidence-based practice guidelines, the
dietary restriction of sodium intake, life style changes, ongoing monitoring, and
documentation of patient status and functional class. Additionally, fluid intake
restrictions may also be recommended for some patients (Duffy, Hoskins, & Chen, 2004;
Mant, Al-Mohammad, Swan, & Laramee, 2011; Whitlock, 2010). Evidence shows that
first line therapy treatment with beta-blockers (b-blockers) and angiotensin converting
enzyme inhibitor (ACE-I) improve quality of life and reduce morbidity (Mant, AlMohammad, Swan, & Laramee, 2011). Additionally, diuretics are commonly used to
manage fluid balance, treat dyspnea, and minimize edema (Butler, 2010; Tansey, 2010).
Medications are used in conjunction with recommendations for life-style modifications
such as following a low-sodium diet. Despite the established evidence based care
recommendations, there continues to be inadequate treatment and variations in care
delivery across physician practices. IMPROVE HF was a prospective cohort study
examining the therapy use data on patients (N= 15,381) diagnosed with chronic HF and
reduced ejection fraction (EF) < 35% to examine the patterns of care for HF patients in
the outpatient setting. Seven care metrics were examined, including; use of ACE-I, use
of b-blocker, aldosterone inhibitor, anticoagulation in patients with atrial fibrillation,
implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy, and
documentation of HF education. The results indicated there is a wide variation in care
consistency across physician practices with no practice providing optimal care to more
than 62% of the patients (Fonarow et al., 2008).
Regardless of the etiology, once HF has developed, a major risk associated with
symptom exacerbation, worsening HF, and mortality is lack of adherence to treatment
(White, 2005). Lack of adherence to dietary sodium restriction and fluid intake
guidelines, medication regimes, and follow up recommendations can lead to increased
HF symptoms (Evangelista et al., 2003; George & Shalansky, 2006). Treatment nonadherence in HF patients is associated with increased morbidity and mortality and poor
compliance is associated with decreased quality of life, increased healthcare costs, and
hospital readmission. Increased fluid volume and repeat hospitalizations secondary to
exacerbation of HF is considered a predictor of poor prognosis (Albert, Buchsbaum, &
Li, 2007). Adherence to medication regime and life-style changes, including low sodium
diet, is an integral part of HF treatment guidelines and requires patient participation.
Multiple issues affect the development of HF occurrence and HF patient
hospitalizations, among which are increasing prevalence of predisposing factors,
unhealthy habits and lifestyle, inconsistent or inadequate care, and treatment nonadherence. The increased incidence of HF symptom exacerbation leads in turn to
decreased quality of life, increased family and financial burden, and increased stress on
the healthcare system. Managing predisposing factors through risk factor modification,
standardizing care based on evidence-based guidelines, and treatment adherence can help
to decrease the prevalence of HF and HF exacerbation leading to hospitalization.
Evidence-based guidelines help to standardize and direct care; therefore, utilizing
guidelines for providers, nurses, and multi-disciplinary care providers in order to direct
and optimize care should lead to consistency in care standards and prevent symptom
exacerbation, improving quality of life and decreasing healthcare costs for HF patients
Potential limitations exist in accurate identification and scheduling of heart failure
patients by the clerical staff. Attempts to educate the scheduling personnel were made
prior to initiation of the project. Additionally, failure to capture a sufficient amount of
patients during the limited study period may have contributed to an inability to truly
assess the effectiveness of the process improvement compared to the usual process.
Ongoing assessment of the process can be accomplished based on the long-term goal
assessment of decreased exacerbation and hospital admission rates. Additionally,
potential bias of patient outcomes may exist related to the clinic specialty and many
patients having bi-ventricular cardiac resynchronizations devices; however, the focus of
the project was more on the care process than care outcomes. Care outcomes with
evidence-based care utilization have been well established as described in the literature
Definitions of Term
Care pathway, clinical pathway, clinical guidelines: evidence-based,
multidisciplinary care plans that create a guide containing essential steps, recommended
in the care of patients with a specific diagnosis.
Heart failure (HF): A term given for the heartâ€™s inability to sufficiently pump the
blood throughout the body to meet the bodyâ€™s metabolic needs.
End stage heart failure: Marked symptoms at rest despite optimal medical therapy.
Ejection fraction (EF): A measurement of the percentage of blood, ejected by the heart,
during a diastolic cycle.
New York Heart Association functional class (NYHA): Method used to grade heart failure
severity based on patient symptoms classified into 4 levels as follows: no shortness of
breath with routine activities of daily living which are (NYHA class I), shortness of
breath with long walks or climbing several flights of stairs (NYHA class II), shortness of
breath with short walks (NYHA class III), or shortness of breath at rest (NYHA class IV).
Palliative care: care that focuses on relieving and preventing suffering, utilizing a
multidisciplinary approach, which is appropriate for patients in all disease stages,
including those undergoing treatment for curable illnesses, living with chronic diseases,
or nearing the end of life.
Return on Investment (ROI): Performance measure used to evaluate the efficiency of an
investment, calculated by the benefit (return) of an investment divided by the cost of the
investment; expressed as a percentage or a ratio.
HF continues to be a major public health concern affecting 5.8 million people in
the United States and accounting for one of the most frequent causes of hospitalization
and hospital readmissions annually (Center for Disease Control and Prevention, 2013).
Efforts to reduce hospital admissions and readmissions may favorably impact the
patientâ€™s quality of life, the family dynamic and the burden on the health care system.
While efforts at reducing HF readmissions should start while the patient is in the hospital,
admission and readmission preventive efforts should take place in the outpatient clinic
through the use of EBP guided therapy. These efforts include proper preventive measures
and lifestyle modification, patient and family education, the use of early diagnosis and
treatment utilizing EBP guidelines, GDMT, proper documentation of patient status, and
ongoing monitoring with modified treatments and ultimately palliative care as dictated by
the patients status (Hauptman, et al., 2008). Outpatient HF clinics have been proven
effective as an adjunct to symptom management but exact ROI is difficult to calculate
and potentially unappealing to for-profit health systems unless tangible and intangible
benefits out -weigh the expense.
The magnitude of the problem with HF care has been discussed and the
importance of finding solutions to care, for all HF patients and the community involved
in this study, has been highlighted. A review of the literature was done to guide the
development of the project and contribute to the adequate understanding of the necessary
components needed to complete the project and is reviewed in chapter 2. This review
included the components considered important to comprehensive HF management.
Chapter 3 includes a description of the approach, design, participant recruitment,
protection of subjects, data collection procedures, goals, and methodology for compiling
and analyzing data. Chapter 4 includes results and implications of the study. This chapter
interprets the findings related to limitations, and implications for social change, while
analyzing the researcher from the domains of; scholar, practitioner growth, project
developer, and future professional development. Chapter 5 is a final project evaluation
report that summarizes the project goals, outcomes, areas of future study, and plans for
Chapter 2: Review of the Scholarly Evidence
HF is a well-documented and studied clinical syndrome that affects millions of
Americans at an estimated annual cost of $37 billion dollars (U.S. Department of Health
& Human Services, 2013) and has established care guidelines, quality measures, and
treatment strategies (Lainscak, 2004; Mant, Al-Mohammad, Swan, & Laramee, 2011;
U.S. Department of Health & Human Services, 2013). Prompt recognition of HF
diagnosis upon hospitalization can facilitate appropriate interventions and improved care.
This care should be extended beyond the hospital period and include outpatient care,
education, and palliative care. The following is a brief review of literature surrounding
the components of recommended care for the HF patient. All of the aspects should be
considered when customizing and individualizing the care of patients with this complex
The search for relevant studies was conducted using the CINAHL Plus with
Full Text, Cochrane Database of Systematic Reviews, Dissertations & Thesis at
Walden University, and MEDLINE with Full Text. Google Scholar was also
utilized. The key words adherence, care models, care, clinic, clinical pathway,
disease management, healthcare cost, heart failure, guidelines, inpatient,
outpatient, palliative care, theory of reasoned action, outcomes, and quality,
quality of life were used for the search criteria. For the purposes of this review,
only peer-reviewed articles published in scholarly journals since 2000 were
considered. Industry recognized medical and government websites for statistical
data including the American College of Cardiology, the American Heart
Association, the Center for Disease Control, the Florida Department of Health, the
Joint Commission of Hospitals, and the Society of Hospital Medicine were also
Manning, Wendler, and Bauer (2010) described the development and
implementation of an advanced practice nurse-led HF clinic approach to manage the
acute care of HF patients and demonstrated consistent improvement in core monitoring
indicators sustained over time. After development of a mechanism to identify all HF
patients admitted to the hospital, regardless of admitting diagnosis, using criteria such as:
secondary diagnosis, laboratory monitoring results, and case management identification
of patients, the heart failure support team (HFST) led by a nurse practitioner was able to
monitor the care of the HF patient. Upon verifying the diagnosis based on history and/or
EF, the HF patient was then tagged as such in the EMR creating a relationship with the
diagnosis for future encounters. A standardized tool was utilized to be included in the
chart to provide for documentation of HF patient care based on the Joint Commission
(TJC) recommended care measures including documentation of EF and use of ACE-I or
angiotensin receptor blocker (ARB) in those with EF <40%. The outcome of this study
showed that a comprehensive advanced practice nurse led HF management program
improved adherence to TJC core measures regarding HF care (Manning, 2010).
Similarly, Kay et al. (2006) performed a review of the Carolina Healthcare
System HF care, for the purpose of improving HF care compliance with TJC core
measures, and controlling cost and showed care to be fragmented. The assumption was
made that hospital readmissions could be prevented through closer follow up care and
more aggressive therapy. The establishment of an interdisciplinary committee to evaluate
programs and recommend changes spearheaded the development of an improved care
delivery system that focused on intensive staff education regarding disease management,
medication interventions, smoking cessation, and nutritional counseling. The outcome
reflected a reduction in 30-day HF readmission rates from 7.3% to 1.7% and mortality
declined by 25%. These improvements were brought about in part by improved cardiac
discharge instructions and homecare services that included patient needs assessment prior
to discharge, home clinical pathway, behavior modification, and cardiac monitoring
consisting of daily BP, heart rate, and weight(Kay et al., 2006).
Another approach to inpatient HF management was developed and reported by
Discher, Klein, Pierce, Levine, A. B., and Levine, B. (2003) which included a nurse
case-managed HF program (Discher, Klein, Pierce, Levine, & Levine, 2003). The
purpose of the study was not to develop a specialized HF unit but rather a nurse case
management HF program, implementing practice guidelines that were extended to
diverse providers encountering the challenges of large variation of practice among
providers and reluctance to adhere to guidelines. The researchers in this retrospective
study examined the outcome effects of this disease management program implemented in
a hospital setting. The program included the development of a HF algorithm and clinical
pathway, the development of educational programs for physicians and nursing staff
competency in HF care, and the development of patient educational materials. All
materials were based on Agency for Healthcare Policy and Research (AHCRP) clinical
criteria for HF. The program goal was to improve care while lowering cost, decrease the
length of stay, increase usage of AHCRP care criteria for HF patients, and maintain staff
satisfaction. The outcome showed that patients in the managed group (n=396) had
significantly increased documentation of left ventricular dysfunction and ACE-I use,
lower length of stay (3.9+2.2 vs 6.1+2.8 days, p<.001)) and a significant reduction in cost
($4404+$1989 vs $6828+ $3347, p<.0001) compared to the unmanaged group (n=197).
These improvements were sustained at one year with the success of the program
attributed to clinical pathway algorithm, staff education, and inpatient follow-up by
nursing case managers (Discher, Klein, Pierce, Levine, & Levine, 2003).
Formal HF disease management clinics have become a recognized way to deliver
coordinated care to the HF patient. Lainscak (2004) studied the effect of treatment
strategies provided at HF clinics in a prospective cohort study of all patients referred to
the HF clinic. Those with signs and symptoms of HF, LVEF <45%, and at least 3 visits to
the HF clinic were included, with patients acting as his or her own control in before and
after intervention data collection. Extensive medical history, physical exam, and
echocardiogram were done at the initial visit. Patients and their care providers received a
45- minute initial consultation with the physician that included instruction on disease
process, recognition of signs and symptoms of worsening condition, importance of
adherence to prescribed medications and non-pharmacological measures such as fluid and
sodium restriction, physical activity, and risk factor modification. Prior to the study, there
were 52 hospitalizations (.81 per patient) for HF amongst the cohort. After intervention,
14 hospitalizations (.57 per patient) reflected a reduction of 73%. Knowledge regarding
HF was assessed at baseline with questionnaire prior to first contact with the physician;
follow up questionnaire results after the third visit showed significant improvement.
Pharmacological management analysis showed an improvement in the use and dosages of
guideline-recommended medications. The study results showed that coordination of
outpatient care, patient education, and follow up helped to improve, patient knowledge,
adherence to EBP guidelines, outcomes, and perceived quality of life (Lainscak, 2004).
Similarly a descriptive, qualitative study done by Crowder (2006) using
ethnographic interviewing of participants (N=15) at an outpatient HF clinic showed
participants had self-reported improved quality of life and symptom management.
Twelve (80%) of the participants were referred by providers due to repeat HF
hospitalizations and the remaining participants were self or family referred. All
participants had NYHA class III-IV HF symptoms and reported an improvement in
quality of life attributed to being enrolled in the HF clinic (Crowder, 2006).
Sochalski et al. (2009) found similar results in outcomes for HF patients. The
study analyzed data from 10 randomized clinical trials of HF care management programs,
including those trials run by certified HF nurses or advanced practice nurses (n= 6). The
reveiw found that multi-disciplinary managed care program patients had fewer hospital
readmissions than patients receiving routine care (Sochalski, et al., 2009).
The importance of outpatient follow up of HF patients was demonstrated in a
systematic review of non-pharmacological strategies for improving HF outcomes by
Duffy, Hoskins, and Chen (2004). The reviewers examined 15 research studies which
met inclusion criteria of randomized controlled trial and minimally acceptable HF study
assessment score (HFSAS) of 13. The HFSAS is an evaluation tool designed to analyze
HF studies and includes items such as sample size, timeline, and NYHA functional class.
All of the studies included an intervention and a control group, with randomly assigned
participants, having an average age 71.5 years, with predominantly NYHA functional
class III symptoms, and a predominantly male cohort. The care was delivered by a multidisciplinary team 73% of the time and nurse-led care 26% of the time. Care delivered
included education, close monitoring, family and emotional support, team collaboration,
and telephone contact. The results reported in the studies were decreased hospital
readmissions and the same or improved quality of life with cost of care staying the same
or reduced in all studies but one (Duffy, Hoskins, & Chen, 2004). This review
demonstrated the importance of non-pharmacological measures and comprehensive care
to treat HF, improve outcomes, improve quality of life, and decrease cost.
HF affects 1-2% of the developed world, with greater than 10% of the elderly
population eventually developing this syndrome (Gadoud, Jenkins, & Hogg, 2013). The
lifetime prevalence of HF is 15-20% in all adults with the risk for developing this
syndrome increasing with age. HF patients can suffer with severe symptoms which
include pain, anxiety, disability, and eventually death, with a 30-50% mortality rate
within 5 years after the first HF hospitalization. The caregivers of these patients also
experience a high degree of burden and stress (Howlett, 2011).
Palliative care, which involves the promotion of physical and psychological
health, has been a recognized part of end of life care for patients with malignancy but has
not been associated with care of the HF patient until recently. Howlett (2011) discussed
the reasoning why palliative care is not a consistent part of the HF patients care plan.
These reasons include the inability to precisely predict life expectancy in HF patients,
episodes of sudden death in otherwise stable, compensated HF patients, therapies used for
the treatment and symptom control of HF often prolong life, misunderstanding by
patients, caregivers and some providers regarding the role of palliative care, and
unwillingness by some providers to discuss end-of-life issues.
Recommendations for palliative care plan coincide with the stages of HF which
include Stage 1, the chronic disease management phase; Stage 2, supportive and
palliative care phase; and Stage 3, terminal care phase. During Stage1 symptoms are
generally NYHA functional class III and the goals of palliative care include; active
monitoring, prolonging survival, symptom control, patient and caregiver education, and
self- management. Stage 2 coincides with NYHA functional class III-IV and most likely
increased hospitalization events. This phase has goals more consistent with symptom
management, multidisciplinary needs assessment, discussion of the prognosis and likely
course of the disease, and advance directive planning. Stage 3 is end-stage disease with
symptom control, increased practical care and emotional support, and a formalized plan
for resuscitation status addressed. This phase may continue to bereavement support for
the caregivers and family (Howlett, 2011).
Howlett (2011) reviewed a general guideline for the inclusion of palliative care
services in the HF patient care pathway, with recommendations for each stage of HF,
including emphasis on reevaluating goals of therapy as the disease progresses. The
recommendation is to approach the patient early in the disease process regarding
prognosis, advanced directives, and resuscitation status, identification of a healthcare
surrogate, support with psychosocial issues including respite care, and evaluation of
coping and caregiver burden (Howlett, 2011).
National and international guidelines recommend palliative care as an integral
part of HF management (National Clinical Guideline Cemtre, 2010). Gadoud, Jenkins,
and Hogg (2013) discussed the gaps in care related to the HF patient in regards to
palliative care. Factors related to inequities and barriers in providing palliative care to HF
patients include; difficulty by clinicians in discussing the poor prognosis associated with
HF, fear of causing alarm in patients and families, fear of destroying patientâ€™s hope,
limited time for conversations because of busy clinics, and the medical model focus on
prevention of death (Gadoud, Jenkins, & Hogg, 2013). Goals of palliative care presented
by Gadoud (2013) include symptom control, holistic assessment and support for all
domains including; physical, spiritual, open communication, and medical and device
therapy. The importance of accurate prognosis and specific symptom management
including the management of dyspnea, edema, fatigue, and pain is a desired goal as well
as the utilization of an integrated team approach.
Evidence supports that providers and doctors agree with palliative care for HF
patients. Hanratty et al. (2002) investigated doctorsâ€™ perception of palliative care in a
explorative, qualitative study conducted in Northwest England involved a variety of
providers (N=29) including general practitioners, consultants in cardiology, geriatricians,
and palliative care providers. This study used focus groups to facilitate identification of
topics of interest to each provider. The results revealed that there was a lack of
coordination of care for the HF patient secondary to repeated hospital admissions under
the care of different providers and lack of community support. The group agreed that
difficulty with prognostics and the unstable trajectory of the progression of HF leads to
difficulty with palliative care services. A common belief that palliative care doctors have
difficulty treating HF was held by the group (Hanratty et al., 2002). There was a
consensus of the participants regarding the need for the inclusion of palliative care with
HF and a clarification of the roles of providers. Barriers identified arose from
coordination of care, prognosis and course of HF, and views of colleaguesâ€™ roles.
Additionally, recommendations for specialist nurses and general practitioners that could
act as care coordinators were deemed a central component of palliative care services
(Hanratty et al., 2002)..
The science related to the treatment of HF continues to evolve and includes
inpatient and outpatient care. The American College of Cardiology Foundation and the
American Heart Association (ACCF/AHA) task force have been producing EBP
guidelines since 1980 (American College of Cardiology Foundation/American Heart
Association, 2013). These guidelines include the definition of HF based on the NYHA
functional class, staging guidelines based on disease processes and progression,
pharmacological strategies for the treatment of HF, explanation of stages of HF with
recommended treatments for each stage, indications for cardiac resynchronization device
placement guidelines, and recommendations for care on hospital discharge including
prompt follow-up care recommendations, with multidisciplinary disease management
which includes palliative care. These guidelines are scrutinized annually and updated as
needed with the most recent update completed in 2013.
The ACCF/AHA guidelines stress the importance of risk factor modification,
early detection, and the prevention or reduction of morbidity and mortality (Yancy,
Krunholz, & Ryan, 2013).The guidelines are written by a committee of selected experts
and utilize evidence-based recommendations with the class of the recommendation being
an estimate of the size of the treatment effect designated by classification I, IIA, IIB, and
III, with I being benefit outweighing risk and III being no benefit or potentially harmful.
The level of evidence representing the level of certainty or precision of effect designated
by A through C, with A being utilized in multiple population and C being utilized in
limited populations (American College of Cardiology Foundation/American Heart
The National Institute for Health and Clinical Excellence (NICE) has similar
guidelines for HF care which strive to promote patient centered care by considering
individual needs and preferences, through communication and education, to allow
patients to reach decisions regarding their care based on evidence-based information.
These guidelines were developed in London and are utilized in Europe and are consistent
with the ACCF/AHA guidelines with recommendations regarding diagnosis, functional
class, staging, treatment modalities including medications, life-style modification,
monitoring, rehabilitation, discharge planning, discussions regarding prognosis, and
palliative care (National Clinical Guideline Cemtre, 2010).
The Institute for Clinical Systems Improvement (ICSI) also provides guidelines
for the care of the HF patient with a system in place for frequent updates as new evidence
emerges and guidelines change (Pinkerman, et al., 2013). These resources are
comprehensive, researched based guides that are complete and succinct, covering many
areas including classification of disease, inpatient and outpatient care guidelines, and
tools for adherence.
The Heart failure Society of America (HFSA) has published a consensus
statement regarding HF care. This statement acknowledges that the treatment of HF
should occur on a continuum from acute care episodic treatment requiring hospitalization
through chronic care management in the outpatient office setting. Recommendations for
the outpatient setting include; prompt follow up within 7 days or less of hospitalization,
early identification of symptom progression, evidenced- based medical therapy, quality of
life evaluation, and patient and family education to improve adherence to medical
regimens and treatment plans. This is especially important when recognizing that
outpatient care accounts for a significant portion of HF expenditures with HF being the
leading cause of for outpatient visits in the Medicare population (Hauptman, et al., 2008).
HFSA also recommends patients and their family members or caregivers receive
additional education and counseling delivered by a multidisciplinary team. The
guidelines recommend educational instructions include definitions of disease processes,
symptom recognition, medication indication and usage, the importance of risk factor and
life style modification, activity recommendations, and the importance of treatment and
follow up adherence (Rich, et al., 2008).
American Heart Association (AHA) has a goal to improve care for patients with
heart disease and stroke through utilization of their get with the guidelines (GWTG)
program. This program includes modules for patient management tools in patients with
HF, stroke, and coronary artery disease (CAD) that contain patient specific
recommendations that allow for real time data collection and a method for tracking
adherence internally and against national benchmarks. These guidelines are focused
mainly for the inpatient care of the HF patient and have shown improvement in
documentation of process of care in a study comparing 215 hospitals enrolled in the
GWTG-HF program to other hospitals not enrolled (N=4,245) from 2006-2007. The
GWTG hospitals had significantly higher documentation of left ventricular EF, use of
ACE-I or ARB, and discharge instructions. The GWTG hospitals showed a 30-day
readmission rate that was lower than non-GWTG hospitals (-.33%; 95% CI, -.53% to –
.12%; p=.002), however there was no significant difference in 30-day mortality rate
(Heidenreich, et al., 2012).
Currently care recommendations and interventions for treatment of HF are
consistent across guidelines and include, but are not limited to, the prescribed use of
multiple medications, based on EBP guidelines, the dietary restrictions of sodium intake,
life style changes, ongoing monitoring , and prompt outpatient follow up post
hospitalization ideally within 3-7 days. Additionally, fluid intake restrictions may also be
recommended for some patients (Duffy, Hoskins, & Chen, 2004; Mant, Al-Mohammad,
Swan, & Laramee, 2011; Whitlock, 2010). Despite the improved outcomes found in
clinical trials through management of HF with medications and life-style modification,
because of patient characteristics and inconsistent outpatient care, these benefits may not
be realized in clinical practice. It is estimated that 64% of hospital readmissions are
caused by patient non-adherence to medical regimes and of these 54% could be prevented
Outpatient HF clinics have been shown to improve outcomes, improve quality of
life, and decrease hospitalizations through an organized, consistent approach to care, and
providing prompt follow up (Hauptman et al., 2008; Herrick, 2001). However, in the
absence of an available HF clinic, EBP guideline recommended care should be used. One
method of coordinating care is utilizing clinical pathways to guide the outpatient
treatment plan and should include the recommendations of current EBP research and
Utilizing clinical practice guidelines and pathways to guide care can guide
decisions, promote the utilization of evidence- based research, provide patient-centered
care, form a basis for inter-professional team cooperation, and facilitate quality
improvement efforts (Clutter, 2009). Clinical pathways have become a recognized way of
providing a roadmap for multidisciplinary care for patients, using evidenced based care,
by translating clinical guidelines into protocols tailored to local hospitals and providers.
Multiple terms have been used to describe clinical pathways including; care plans, care
maps, clinical practice protocols, and integrated clinical pathway among a few. The
criteria for defining and development of clinical pathways were studied by Kinsman et
al.(2010), for a Cochrane review, to establish standard characteristics of a clinical
pathway. Their research revealed that there are up to 84 different terms that may mean
clinical pathway. A four stage process was used to develop criteria to define clinical
pathway with results revealing several common criteria including; guiding care for a well
defined group of patients over a specified period of time, goals and key elements of care
are stated based on evidence-based guidelines, a specific sequence of actions utilizing a
multi-disciplinary care team, help communication with patients by providing clearly
written care summary, and provisions for documentation, monitoring, and evaluation of
outcomes and variances (Kinsman, Rotter, James, Snow, & Willis, 2010). Utilizing these
criteria, consistency can be achieved in defining and developing clinical pathways.
Ranjan et al. (2003) performed an 18 month, pre and post- test evaluation of HF
patients stratified to clinical pathway care (n=174) or no clinical pathway (n=197), to
determine if clinical pathway use contributed to decreased length of stay, decreased cost,
and improved care based on the criteria of increased ACE-I usage. Results showed there
was significant reduction in hospital length of stay, lower median hospital charges and
increased ACE-I usage in the clinical pathway group (81% vs 48%). This indicated that
the clinical pathway use in patients with HF was associated with a reduction in hospital
length of stay and improvement in quality of care (Ranjan, Tarigopula, Srivastava,
Obasanjo, & Obah, 2003).
The utility of clinical pathways was demonstrated by Allen, Gillon, and Rixson
(2009) through a systematic review of 9 papers, representing 7 randomized control trial
studies was performed to evaluate the effectiveness of integrated care pathways (ICP)
used on adult and pediatric patients, in secondary and tertiary care centers. The goals of
the ICPs were varied but included promoting practice change, improving outcomes,
adherence to best practice guidelines, reducing treatment variations, and improving
quality of care. The pathways covered medical conditions including neck fractures,
pediatric asthma emergency room care, endoscopic surgery care, community acquired
pneumonia, and HF. The review found ICPs are effective for supporting proactive care
and ensuring timely clinical assessment and intervention, promoting adherence to
recommended guidelines reducing variation in care, improving documentation,
improving provider agreement regarding treatment options, providing decision support,
providing role direction and directing professional practice. The ICPs were not found to
be helpful when extreme flexibility of care is needed, for diagnosis with unpredictable
courses, and when used in cases where best evidence and a successful multidisciplinary
approach have been well established. The use of ICPs was found to be most beneficial in
the case where there is identified service or quality deficiencies. (Allen, Gillen, &
The logic model (Appendix A) was used for the HF care improvement project.
This model has been used across many professions including academics, nursing and
public health, management fields, business and sociology to name a few and will help to
facilitate practice change by examining the inputs, processes and outcomes of the
intervention. The CDC uses the logic model for their Heart Disease and Stroke
prevention program and evaluation (Department of Health and Human Services, 2006). It
was appropriate for this project as the goals of the project were to standardize care and
change the current practice of HF care at an outpatient clinic. Care standardization was
done through the utilization of a clinical pathway to guide a nurse-led HF clinic, utilizing
inputs such as stakeholder assistance in the development process and tools for process
change, implementing the process change, and monitoring of outputs and outcomes
The logic model as the framework for the intervention helped to guide and to
organize the process. It allowed for communication of the program purpose, description
of actions intended to lead to desired results, improve program staff knowledge,
involvement of stakeholders including patients and providers, and identification of
obstacles to program success (Kettner, Moroney, & Martin, 2008; Knowlton & Phillips,
2013). The model is generally made up of three or four core elements including inputs,
process, outputs, and outcomes. For the purposes of this project, inputs, process, outputs,
short-term and intermediate outcomes were utilized. Long-term outcomes will be
Inputs in this case are the stakeholders which include nursing staff, physician and
nurse practitioner providers, multi-disciplinary care team involved in the HF quality
improvement process, the HF patient and resources. The input from the providers and
team were utilized as appropriate for this project as the goals of the project were to
change the current practice of HF care at an outpatient clinic through the development of
a nurse-led HF clinic. The stakeholder assistance in the development process and tools
for process change, implementation of the process change, and monitoring of outputs and
outcomes helped to shape the program during development, implementation and
evaluation. The patients input were utilized during the teaching process by examining
their specific needs and tailoring interventions to coincide with them as much as possible.
The resources were the tools utilized for teaching and data collection. The teaching tools
included basic instruction on disease process, medication adherence, life-style
modification, signs and symptoms, and follow up care.
The process included the activities necessary to establish the HF clinic. This
consisted of utilization of EBP treatments, outpatient follow up care, and resources. The
EBP treatments were based on recommended guidelines established by the ACCF/AHA,
HFSA, and NICE (American College of Cardiology Foundation/American Heart
Association, 2013; Hauptman, et al., 2008; National Institutes of Health, 2012).The
outputs were the activities included in the program effecting the clients or stakeholders
that these activities served which included; total number of patients that become enrolled
in the HF program, number of patients being treated utilizing the appropriate clinical
pathway GDMT, appropriate documentation of NYHA functional class and advanced
directives, number of patients completing education component regarding prescribed
medication and lifestyle recommendations and number of patients with appropriate
therapies or reasons why not documented. Also the number of contacts per individual
patient, including phone contact, was monitored.
The outcomes were defined in terms of short, intermediate and long-term goals
related to the program impact and can be used to evaluate the success of the program.
The short-term goals were the development and institution of the clinical pathway and
education program. The intermediate goals were implementation of a Nurse-led HF clinic
pilot program, improved quality of care based on the utilization of evidenced-based
guidelines including; patient education, timely follow-up, and treatments based on stages
of disease progression. The long-term goals were decreased symptom exacerbation
events, decreased frequency of hospital readmissions, improved quality of life and
decreased financial burden having a positive impact on the health care system which will
be evaluated later.
The components of HF care are well described in guidelines that are frequently
updated and include inpatient care, outpatient care, and palliative care recommendations
(American College of Cardiology Foundation/American Heart Association, 2013). The
care process can be coordinated with the use of clinical pathways to guide care (Ranjan,
Tarigopula, Srivastava, Obasanjo, & Obah, 2003). What remained to be discovered was if
the care process could be improved at this outpatient cardiology clinic, if all providers
would utilize the clinical pathways, and if the utilization of the clinical pathways would
increase over time. Utilizing a logic model as a framework for this study, Chapter 3
reviews full details of design, population selection and sampling, protection of subjects,
data collection, and evaluation criteria. Project results and implications are reviewed in
Chapter 4 and Chapter 5 contains the project evaluation report.
Chapter 3: Approach
The outpatient HF care project was a process improvement project. The
intervention was to develop a coordinated plan of care for the HF patient cared for in the
outpatient clinic, with the focus on clinical pathway development, education of the key
stakeholders, enrollment of patients in a HF care clinic in order to examine the effects of
coordinated care and utilization of EBP guidelines to change the current practice of HF
care at an outpatient clinic.
The project to improve the care of the outpatient HF patient was developed as a
process improvement pilot study. The initial implementation and data collection portion
of the study was carried out over an 4-6 week period (Appendix B), coordinating the care
for a group of HF patients cared for at a small cardiology clinic and associated for-profit
hospital in Central Florida. The primary goal was to promote standardized continuity and
consistency of care including timely, appropriate care through utilization of EBP
guidelines and GDMT, in an effort to improve care and documentation, increase patient
self-care through patient adherence to diet, lifestyle, and follow up recommendations,
while increasing the patientâ€™s understanding of signs and symptoms of disease
progression. The secondary goal was to comply with the Joint Commission Core
measures for care of the HF patient in the outpatient clinic.
Data on the enrolled patients were collected concerning the current care and
frequency of HF admissions. Inputs included the multidisciplinary hospital quality
improvement team and the stakeholders involved in the outpatient arena including
providers, staff, and patients. The hospital quality improvement team was utilized to
establish an avenue for referral to the HF clinic and point of contact for information on
hospitalized patients, inpatient care if any, to assist patient transition to outpatient follow
up, and for dissemination of project results
The stakeholder group in the outpatient cardiology clinic consists of nurse
practitioners, nurses, clerical staff, and collaborating physician. This interdisciplinary,
collaborative team reviewed developed HF care pathways, implemented developed care
pathways, assessed teaching plan, selected target patients, and initiated interventions.
After enrollment of patients, the HF pathway was implemented which included
instruction on medication and life style recommendations, diet, treatment adherence,
symptom monitoring and management, and follow up visits. Follow up clinic visits for
provider assessment and further teaching as needed was performed and nurse call back
contacts were scheduled.
Those patients included in the study had an initial evaluation by the nurse
practitioner followed by an instruction session with the nurse practitioner or a registered
nurse who had been educated on the necessary content. Educational materials were
provided to the patient and/or caregiver. Follow up contact was made within 2 weeks by
phone on high-risk patients to assess patient understanding and discern if there were any
difficulties with diet, medication, or symptom monitoring adherence. A face-to- face
follow up visit was scheduled for those patients with acute symptoms. Assessment by the
nurse practitioner or provider occurred at the onset of program admission, within 2 weeks
of medication changes, 1 week of hospital discharge, or more frequently if the patientâ€™s
condition dictated. Those patients with devices had the device interrogated at least once
in the study period. The outputs or outcomes were assessed at the completion of the study
period and included documentation of total patients enrolled, patients enrolled per week
and per provider, appropriate use of medications, NYHA functional class, advanced
directives, teaching intervention, number of hospitalizations during the study period, and
follow up contacts scheduled.
Population and Sample
The population for the outpatient portion of this project was a convenience,
random sample selected from patients attending a cardiology practice associated with a
for-profit hospital system, located in Florida. The study participants were selected from
each of the two-physician providerâ€™s patient population based on availability or recent
hospitalization. Inclusion criteria included the adult patients with a diagnosis of HF
associated with cardiomyopathy and reduced EF. Patients had a documented EF < 40% at
some point in time, had a NYHA class II symptoms or greater, and had the ability to
consent to study participation and understand instructions or had a responsible caregiver
willing to participate and give consent.
Exclusion criteria was a terminal diagnosis with impending demise anticipated,
residency in an assisted living or long-term care facility with no ability to regulate food
choices, medications, and symptom reporting, inability to understand instructions, no
access to a telephone, or unwillingness to participate.
Data as to current medications used, the non-pharmacological interventions, the
documentation of symptoms, and hospital admissions for HF were collected on the
sample population based on documentation in the clinic medical record and during each
visit. Documentation of completion of education, number of sessions, number of
telephone contacts, medications, NYHA functional class, symptom exacerbation if any
were performed utilizing a portion of a data collection tool that was developed for the
IMPROVE- HF clinical trial (Medtronic Inc, 2005) and utilizing and EMR, HF specific
flow sheet (Appendix C). Data was not collected regarding prior hospital admission on
each patient in the past year; however, follow up data regarding readmissions during and
post-intervention began during the implementation and continues, utilizing available
reports from the hospital HF quality improvement team and patient self-report if
Protection of Subjects
As there is no IRB committee at the designated outpatient clinic or associated
hospital, approval for data collection regarding patient information was obtained from the
physician practice manager and the patient. Approval for hospital data collection
regarding admission statistics was provided by the director of quality improvement, data
signed by each patient seen at this cardiology practice. Patients were de-identified for the
purposes of study data analysis. As the education component was considered part of the
standard pathway practice the number of HF specific education sessions was reviewed
but not reported as a component of the overall analysis. Protection of subjects was
insured by submission of standard IRB approval request and verification of approval by
the Walden University IRB committee. The IRB approval number for this study was 08-
The goals of the program were to improve the process of care of the outpatient HF
patient, promote standardized continuity and consistency of care, utilizing EBP
guidelines which includes timely follow up, through the development of clinical
pathways. The pathway (Appendix D) was used to promote increased understanding by
stakeholders including staff and patients regarding HF symptoms, standard medications,
lifestyle guidelines, and follow up care recommendations, while establishing the
framework for nurse-led HF care. Additionally, promotion of multi-disciplinary
collaboration in the outpatient setting while developing the program was evaluated based
on provider involvement. The evaluation of implementation effectiveness was assessed
based on 3 of the 2014 Joint Commission Standards core measures for outpatient HF
care. The core measures examined include documentation of the following:
ACHFOP-01: Hospital outpatient documentation of b-blocker therapy (i.e., bisoprolol,
carvedilol, or sustained-release metoprolol succinate) prescribed for left ventricular
systolic dysfunction (LVSD).
ACHFOP-02: Hospital outpatient documentation of ACE-I or ARB therapy prescribed
for patients with LVSD.
ACHFOP-04: Hospital outpatient documentation of NYHA functional classification for
patients with HF (The Joint Commission, 2014).
The short-term goal of team development and establishment of a clinical pathway
tool with staff education on use was evaluated and considered successful by completion
of this portion within 7 days. The intermediate goals of selection and enrollment of
appropriate patients on which to initiate the pathway, initial contact and education of
these patients, and scheduled follow up contacts was evaluated after 4-6 weeks of clinical
pathway initiation. Success was defined as successful completion and documentation of
all tasks including; documentation of NYHA heart failure functional class, appropriate
medication usage or reasons for not using it, documentation of education, and phone or
follow up contact performed on at least 80% of the enrollees. The goal of team
collaboration and utilization of clinical pathway was assessed as successful on a pass or
The long-term goals will be evaluated later, after completion of the main project.
These will include performing continued quality monitoring using criteria established by
the Joint Commission for Hospitals regarding HF care and assessing for signs of
increased patient adherence, decreased symptoms, decreased hospital readmission,
decreased cost, and improved quality of life to be evaluated on an ongoing basis in 9-12
months after completion of the main project and based primarily on burden or frequency
of hospital readmissions or worsened HF class. Further progress regarding the
development of a nurse-led HF clinic will continue to be monitored and based on a
succeed/not succeed basis and will likely occur after completion of the main project.
The project to improve outpatient HF care was performed utilizing the logic
model for implementation plan development and educational program development and
implementation. A care pathway was used to guide care and an EMR flow sheet was used
to document EBP guidelines and assessment of the HF patient. The convenience sample
was selected from a cardiology practice population with a documented cohort of heart
failure patients. Data were collected utilizing items from the IMPROVE-HF clinical trial
tool and the EMR flow sheet which were tailored around EBP guidelines and TJC core
measures for outpatient HF care
Chapter 4 reviews the project results, implications, and project limitations.
Chapter 4 also discusses analysis as it relates to scholarly growth, practitioner growth,
development as a project leader, and future professional development plans. Chapter 5
provides a project evaluation report.
Chapter 4: Results and Implications
The process improvement project to improve the outpatient care of the HF patient
through clinical pathway implementation developed over a 6-week period. The study
purpose included analyzing the implementation process, team collaboration, and provider
utilization of the pathway, as well as to assess the frequency with which GDMT and
documentation was performed and expose any deficiencies in recommended care based
on EBP guidelines (American College of Cardiology Foundation/American Heart
Association, 2013). These data were intended to be used as the basis for needs assessment
for a nurse-led outpatient HF clinic. Patient specific data regarding blood pressure, heart
rate, arrhythmia, weight, symptoms, medication adherence and life-style adherence were
not evaluated for the purposes of this study. There were three goals and hypotheses
associated with this project.
The primary goal was to analyze the care of HF patients in an outpatient
cardiology clinic related to documented utilization of recommended medications that
include ACE-I and b-blockers, documentation of EF, documentation of NYHA functional
class, documentation of HF specific teaching, presence of advanced directives, and
follow up contact if indicated, and if there was any significant difference in the care
rendered to patients utilizing a HF clinical care pathway. The first null hypothesis was
that there is no difference in care for patients utilizing the heart failure pathway.
The second goal was to analyze the implementation process by evaluating if the
pathways would be utilized by providers and if the pathway would be utilized equally by
all providers. Pathway utilization was tested by monitoring the number of eligible
patients in which each provider utilized the pathway. The second null hypothesis was that
there would be no statistical difference between provider and pathway utilization.
The final goal was to assess if increased exposure and familiarity to the pathway
tool would affect acceptance and pathway utilization. Pathway acceptance over time was
tested by tracking the pathway utilization on eligible patients each week. The third null
hypothesis was there would be no difference in pathway utilization based on the week of
The initial 4 weeks of the project were spent identifying eligible patients and
implementing the pathway. Of all patients seen (N= 296)) by 5 providers, 2 MDs and 3
nurse practitioners, 27% were identified as eligible (n=80). Patients were identified as
eligible for inclusion if they had a diagnosis of HF and had documentation, at some point
in time, of an EF of less than 40%. The data were classified and examined using the
SPSS21 software (IBM, 2013). Frequency statistical data examined on eligible patients
included provider, week of implementation in which contact occurred, if the patient was
started on the pathway, documented prescription of Ace-I and b-blocker, documentation
of EF, documentation of NYHA functional class, initial HF specific teaching, advanced
directive documentation, and follow up contact within 6 weeks performed or scheduled.
Correlation data was examined using Pearson chi-square or nonparametric tests to
assess pathway utilization by provider and project implementation week. Chi- square was
also used to analyze correlations between pathway utilization effect on prescription of
Ace-I and b-blocker, documentation of EF, documentation of NYHA functional class, HF
specific teaching, advanced directive documentation, and follow up contact scheduled
within the 6-week period. The scheduled contact monitored was phone assessments made
by the nursing staff based on recommendations by the provider because of patient highrisk status for hospitalization. This determination was based on the patients past patterns
of hospitalization or calls for urgent office visits. Additional frequency data was collected
on those scheduled follow up appointments (n=12) regarding contact type, number of
contacts, teaching, symptom exacerbation, scheduled provider follow up, and any
hospitalizations. The analysis of the specific phone interventions was not done for
purposes of this study.
Summary of Findings
Examination of pathway utilization on eligible patients (Table 1) showed that
there was moderate utilization, with 50% of the eligible patients being started on the
pathway (n=40). The following is a discussion of the frequency of variable outcomes
documented that occurred on all eligible patients (N=80), whether they were on or not on
the pathway. Documentation of the utilization of appropriate medications on all eligible
patients was high with 80% (n=64) for ACE-I, and 95% (n=76) for b-blockers.
Examination was also done on the percent and numbers of patients in which
documentation of the following variables was performed, the results are as follows. EF
was documented consistently on 98% (n=78) of the patients. NYHA functional class was
documented a moderate amount occurring on 55% (n=44) of the patients. Documentation
of Advanced Directives was found to occur very infrequently regardless of whether the
patient was on or off the pathway occurring only on 8% (n=6) of the patients. HF specific
teaching 29% (n=23), and follow up contacts 24% (n=19) was also inconsistent. The
outcome of the frequency data analysis for the variables is highlighted in Table 1
Frequency Data on Pathway Utilization and Variables
Variable Frequency (N) Percent (%) Valid percent
Pathway initiated 40 50.0 50.0
ACE-I 64 80.0 80.0
B-blocker 76 95.0 95.0
Ejection fraction 78 97.5 97.5
NYHA class 44 55.0 55.0
Adv. directives 6 7.5 7.5
HF teaching 23 28.8 28.8
Follow up contact 19 23.8 23.8
Following patient enrollment on the HF pathway, higher risk patients were
identified by the providers, based on past-history or current symptoms, for follow up
phone calls by an RN or clinic appointments with a provider, which was to occur within
two weeks. A questionnaire (Figure 1) was utilized for the follow up phone contacts to
assess patient status, understanding of disease process, and document any areas of
increased educational needs. Of the 12 patients contacted by phone, 3 patients had
hospitalizations. Two of the patients were hospitalized with arrhythmias and no related
HF symptoms and 1 patient was hospitalized with recurrent HF. One patient had an
urgent clinic visit, which was not HF related prior to the phone contact and was placed
back on the call list. Two patients had follow up visits scheduled at the time of the
original appointment with a provider to assess medication changes. There were no clinic
visits for additional education performed by an RN because of lack of patient interest
secondary to time or additional co-pay costs. Offers to waive charges did not increase
Patient Name: __________________________ Date: ____________
1. How have you been feeling, have you been to the hospital since we saw you last?
2. Are you having any: Increased Shortness of breath or difficulty lying flat?
3. Are you having any increased fatigue?
4. How much activity are you doing each day or are you having increased difficulty with
5. Are you having swelling in legs
6. Are you weighing yourself daily and have you gained any weight/how much?
7. How is your BP and pulse?
8. How is your appetite, are you following a low sodium diet?
9. Are you taking your medications?
10. Do you have any questions or concerns?
11. Do you know when you should call the Doctor?
Figure 1. Call back patient questionnaire
Correlation Data Outcomes
In many areas, there was no statistically significant difference in care of the
patients on the pathway. There were no statistical differences in the utilization of
guideline recommended ACE-I and b-blocker therapy whether patients were on or off the
pathway. Additionally, while EF was documented consistently for all patients, there was
a statistical difference in documentation of symptoms utilizing the NYHA functional
37.12, df 1, p =.000) and follow up contacts scheduled (x2 5.59, df 1, p =.018)
between those on the pathway and not on the pathway. The conclusion that there was a
difference in some aspects of care for those on the pathway leads to rejection of the first
Pathway Utilization by Provider
Correlation statistics run on the specific provider and pathway utilization (Table
2) indicated that there was a statistical difference between the providers, (x
25.32, df 4,
p=.000) suggesting that some providers were more likely to utilize the pathway than
others. This led to rejection of the second null hypothesis. While 1 nurse practitioner
utilized the pathway on all eligible patients, the other two NURSE PRACTITIONERs
utilized the pathway either not at all (n=0) or very little (n=2, 12%). The two physician
providers utilized the pathway at least 50% of the time.
Pathway Utilization by Provider
Provider Pathway (Yes) Pathway (No) Percent X2 df Significance
NP1 PD 12 0 100
NP2 MN 0 3 0
NP3 DH 2 15 12
MD1 NJ 15 12 56
MD2 SW 11 10 53
Total 40 40 25.32 4 .000
Pathway Utilization by Week
During the implementation process, the utilization of the pathway increased based
on the week of pathway implementation indicating that there was a statistical difference
in the utilization of the pathway based on the week of project implementation (x
3, p=.008). Utilization of the pathway increased as the implementation time of the project
progressed leading to rejection of Null Hypothesis 3 as shown in Table 3.
Pathway Utilization by Week
Week Pathway(Yes) Pathway (No) Total
X2 df Sig.
1 4 20 24
2 11 8 19
3 14 8 22
4 10 5 15
Total 40 40 80 11.94 3 .008
Findings in the Context of HF Care
EBP guidelines and guideline directed medical therapy recommendations are
consistent regarding accurate diagnosis, functional class documentation, treatment
modalities which include; medications, life-style modification, monitoring of patients,
rehabilitation, discussions regarding prognosis, and palliative care (National Clinical
Guideline Cemtre, 2010; American College of Cardiology Foundation/American Heart
Association, 2013). Additionally, utilizing clinical practice guidelines and pathways to
guide care can contribute to decision making, promote the utilization of guideline
directed medical therapy and EBP research, provide patient-centered care, form a basis
for inter-professional team cooperation, and facilitate quality improvement efforts
Ranjan et al. (2003) found an increased utilization of evidence- based care and
documentation utilizing clinical pathways and this project showed similar results
(Ranjan, Tarigopula, Srivastava, Obasanjo, & Obah, 2003). As indicated, there was a
significant correlation between pathway use, documentation of functional class, and
follow up contact with heart failure patients. While many patients not on the pathway
versus received appropriate therapies, documentation of heart failure class for those not
on the pathway versus those on the pathway (n=9, n=35) was not consistent.
Documentation of NYHA functional class in HF patients is considered part of the initial
and serial evaluation process (American College of Cardiology Foundation/American
Heart Association, 2013). Failing to document functional class can make assessing
disease progression difficult.
Contact with high-risk patients for those not on the pathway versus those on the
pathway was also not consistent (n=5, n=14). For those patients not on the pathway, the
follow up contact was a follow up visit with the provider, scheduled at the time of the
original visit. For those on the pathway, a majority of the follow up contacts (n=12) was
by telephone. This contact was generally performed by a nurse, on the request of the
provider, at the time of clinic visit. Some studies have shown an improvement in
outcomes, a reduction in hospitalizations and emergency room visits with phone
telephone follow up and this service should be promoted (Quaglietti, Atwood, Ackerman,
& Froelicher, 2000). The other two follow up contacts were provider visits scheduled at
the time of the original visit to reassess clinical status two weeks after medication
Patients not on the pathway were less likely to receive HF teaching (n=9) than
those on the pathway (n=14), but the difference was not statistically significant. These
areas of deficiency can adversely impact patient care. Non-pharmacological interventions
such adequate teaching regarding diet, medication adherence, symptoms, and life-style
modification are considered a class 1 recommendation (American College of Cardiology
Foundation/American Heart Association, 2013) and should be included in each office
visit. Time constraints at office visits may make this difficult. Additional options for
teaching would be to structure group classes to facilitate patient teaching on a larger scale
or subscribe to multi-media programs to provide to patients utilizing in office I-pads,
television, or provide compact discs for home use.
Recommendations for documentation of advanced directive status and referral to
palliative care are considered part of EBP care and guideline recommended therapy
(American College of Cardiology Foundation/American Heart Association, 2013),
however, this study showed that this is rarely being done at this clinic. Only 6 patients
total (n=3 on pathway, n=3 not on pathway) had documentation of advanced directive
choices. Understanding the patient and familiesâ€™ wishes and planning for future care has
made advanced directive designation and palliative care a recommended part of standard
HF care (American College of Cardiology Foundation/American Heart Association,
This study showed there was a significant correlation between providers who
utilized the pathway and those who didnâ€™t (Table 2). The logic model provided the ability
to assess inputs and processes during the implementation of the project (Department of
Health and Human Services, 2006). Semi-structured interviews during implementation
revealed that while the pathway and HF specific flow sheet were considered useful, time
constraints and remembering to utilize the pathway were given as reasons for lack of
involvement. The pathways were utilized primarily by the nursing staff. These team
members showed a genuine interest and commitment to the project therefore, after the
first week of implementation, changes were made to the process to facilitate utilizing the
tools. Most providers were not likely to utilize the flow sheet if the nurses did not
formally open it in the EMR therefore; the nurses took responsibility for opening the HF
specific flow sheet in the physicians chart. Team collaboration was successful with the
nursing staff and one of the physician providers. Two of the nurse practitioners were less
likely to utilize the pathway and associated flow sheet. Weekly team meetings were
performed associated with educational sessions and individual discussion were held to try
and promote utilization and answer questions.
The goals of this project were similar to those stated by Allen, Gillon, and Rixson
(2009) in a systematic review which included promoting practice change, adherence to
best practice guidelines, reducing treatment variations, improving outcomes, and
improving quality of care (Allen, Gillen, & Rixson, 2009). The outcomes showed some
success at promoting practice change during the course of the implementation period.
While some providers were more likely to be involved in this project than others, as
shown in Table 3, pathway utilization did increase based on the week of the study which
allowed more complete documentation of patient care and facilitated the transfer of
information through the patient EMR which is interoperable among all of this hospital
systems physician practices.
For Practice of Nursing
The role of the Doctor of Nursing Practice ( DNP) prepared nurse includes the
ability to understand and utilize research to guide evidence-based practice in the care of
patients with complex health problems, while maneuvering the challenges of a rapidly
changing healthcare system, and facilitating growth individually and for nursing
collectively (Zaccagnini & Waud White, 2011). These abilities are recommended by the
American Association of Colleges of Nursing (AACN) through their guidelines and
objectives created to structure the educational curriculum, thereby the preparation of the
DNP professional (American Association of Colleges of Nursing, 1999). Continuing
education in nurses is expected to enhance the knowledge and abilities of nurses to
promote lifelong learning and flexibility in role adaptation within the healthcare system
The project to improve the outpatient care of the HF patient was chosen to help
improve the care process and outcomes of patient care, through team building and
nursing contribution, while helping to decrease the burden of repeat hospitalizations on
the patient, family, and health system. The primary endpoint was to develop a system to
better care for the HF patient. During the investigation of literature for this project,
advanced learning and expertise in the management of the HF patient was achieved, team
development occurred, and education of the nursing staff has been a byproduct. While
outcomes have not been miraculous in changing the practice habits of the providers, there
has been a change in some practice patterns and an increase in the awareness by the
nursing staff regarding important aspects of the assessment and care of the HF patient. A
surprising outcome that was revealed was the limited pathway utilization by two of the
nurse practitioners An informal interview with these individuals revealed frustrations due
to lack of time or failing to remember to utilize the pathway. The MD providers had the
assistance of nursing staff when rooming their patients. These individuals played an
active role in initiating the pathways.
Additional, areas in need of improvement were highlighted, most specifically,
discussion of advanced directives and palliative care. The reasons for hesitancy in this
area should be explored. Also, utilizing the phone contact method of triaging patients has
been shown to reduce urgent office visits and emergency room visits (Quaglietti,
Atwood, Ackerman, & Froelicher, 2000). More investigation into utilization of this
service and outcomes related to it should be pursued. Phone triage is an area in which
nurses may be able to impact care by using their education and assessment skills.
For System Change
More than 5 million Americans have a diagnosis of HF and it is a significant
contributing factor to mortality, with half of the people diagnosed with HF expected to
die within 5 years of diagnosis. This occurs at a cost to the healthcare system of
approximately 34 million dollars annually, including the cost of treatment and disability
losses (Center for Disease Control and Prevention, 2013). The impact on national
healthcare spending is tremendous which has prompted efforts by CMS to place a priority
on reducing the number of hospital readmissions, for high -risk diagnosis such as HF,
with-in a 30-day period by financially penalizing hospitals with unacceptable rates.
Avoidance of these penalties has stimulated hospitals and health systems to re-evaluate
the care process for the HF patient (U.S. Department of Health & Human Services,
2013). This project has the potential to favorably affect the care of the HF patient by
focusing on evidence â€“based, guideline directed medical care to manage this disease
condition and prevent hospitalizations. This care can be guided through the utilization of
a clinical pathway to facilitate accurate documentation of treatments, care, and symptoms
which can be integrated into the EMR.
The clinical flow sheet utilized for this project was integrated into the EMR,
which provided an avenue for transfer of information and supports meaningful,
meaningful use of the EMR (Savage, 2013). The developed clinical pathway can be used
in an outpatient HF clinic or in other office practices to guide and coordinate care. A
disease management clinic such as one that cares for the HF patient is a method to
improve care, access, and coordination of care for this population and is an alternative to
the typical care as usual (Nash, Reifsnyder, Fabius, & Pracilio, 2011). This project has
helped to promote interest by hospital administration for the development of an outpatient
HF clinic which would provide a new method of care for the population in the county it
For Future Research
This small process improvement project revealed areas for further research and
study. Utilizing clinical pathways has been shown to be an effective form of care
coordination and disease management (Clutter, 2009). A deficiency in this project was
the utilization of a hard-copy clinical pathway in a system that was primarily
electronically based; therefore, methods to incorporate the pathways into the EMR should
This project did not monitor patient outcomes related to the interventions as the
focus was on process and utilization. Additional investigation into the potential impact of
the clinical pathway and flow sheet utilization, in regards to; improving patient
recognition of symptoms, increasing utilization of guideline directed medical therapy by
providers, and preventing hospital readmissions through outcome monitoring in this area.
In this way, documentation of pathway effectiveness could be monitored.
Of significance was the lack of pathway utilization by two of the nurse
practitioners. Two reasons for this were stated as lack of time, or difficulty remembering
to utilize the pathway. Further research into why this occurred and methods to increase
utilization is warranted. Also, recommendations for potential solutions to encourage
utilization should be researched.
The effectiveness of the clinical pathway in regards to improving the
understanding of recommended care of the HF patients by the nursing staff should be
explored, focusing on outcomes related to nurses understanding guideline directed
medical care. Assessing the nurseâ€™s knowledge base before and after pathway
implementation may shed light on areas of knowledge deficit or methods to improve
Lastly, advanced directive and palliative care are a recommended part of HF care
guidelines (American College of Cardiology Foundation/American Heart Association,
2013). This study found that advanced directives were rarely documented in the patient
EMR. Data were not collected on whether the discussion was approached but not
documented; advanced directive discussion may be an area to investigate further.
Research may be needed into the hesitancy to address advanced directives and palliative
care or lack of understanding regarding this recommendation by providers.
Given the opportunity to repeat this project a different approach may include
educational sessions for the nurses and nurse practitioners to assure understanding of the
clinical pathway and evidence-based, guideline directed medical therapy. These sessions
should include a method for assessing comprehension, prior to institution of the pathway.
More structure would be given to promoting physician provider and clerical staff
understanding to help facilitate proper patient scheduling and pathway utilization by all
providers. Also, an anonymous feedback questionnaire regarding the pathway and its
utilization may help to tailor the pathway to the providers. A more structured approach to
gaining stakeholder input may be helpful to promote increased utilization of the pathway
and HF flow sheet chart tool.
Project Strengths and Limitations
The strengths of this project included the wealth of information and consistency
of recommendations for GDMT and follow up care of the HF patients. These guidelines
provided a firm foundation and rationale for the project variables that were selected. A
second strength was the access to patients at the cardiology clinic who met criteria for the
project. This access offered ample opportunity for patient enrollment. Additionally, there
was support for the project and efforts to find solutions to prevent HF readmissions
because of the profound impact HF readmissions have had on the chosen healthcare
system and the financial bottom line of the associated hospital system (Center for
Medicare and Medicaid Services, 2011). Support for the project by the office
administration and some of the nurses helped to facilitate data collection.
While the physician providers and nurse practitioners were supportive, some did
not play an active role in pathway utilization. This caused a limitation to including all
eligible patients in the study. A second limitation was taking the convenience sample
from one cardiology practice which may have limited data accuracy compared to other
cardiology practices and general practice. A third limitation was utilizing a cardiology
practice which may have skewed the results of pathway effectiveness. The providers may
have preexisting knowledge related to evidence-based, guideline-directed
recommendations for the HF patient care; therefore, the actual effectiveness of the
pathway may not have been fully assessed. Another limitation was the relatively small
sample size (N=80). Utilizing a larger sample size may have revealed more care
differences. A final limitation was the brief data collection time that did not allow for
ongoing assessment of continued or increased use of the pathway.
Recommendations for Reduction of Limitations
To help reduce the limitations of this project the first recommendation is to
provide a method to include the pathway in all relevant patients EMRs, to increase the
potential for the participation of all providers at the associated clinic. Building a hard stop
into the EMR on the HF patients which would trigger the pathway may increase
utilization. An additional recommendation is to test the pathway and its effect on patient
care in other cardiology and general practice clinics to increase the sample size and
evaluate its effect on practices that may not be as familiar with the care of the HF patient.
A third recommendation is to attempt to document any changes in care related to the
pathway through additional data collection over a more prolonged period. The use of care
pathways has been found to be most beneficial when there is identified service or quality
deficiencies. (Allen, Gillen, & Rixson, 2009). Documenting the care deficiencies and
then any changes in care after pathway initiation can help to delineate the effect of the
pathway. Lastly, continuing data collection regarding utilization of the pathway for a
more prolonged time may reveal additional information regarding pathway utilization and
Analysis of Self
Research and project development can provide opportunities for learning from the
standpoint of the practitioner and project developer. The lessons learned can influence
future projects. An important component to continued development as a scholar,
practitioner, and project developer is to analyze the growth after completion studies and
projects. This analysis can provide insight into areas of strengths, weakness, and
directions for future development.
Evaluation of Scholarly Growth
This process has helped me to develop an increased understanding of the
appropriate guideline-directed medical care through research and translation into practice
of evidence-based recommendations. It also has augmented my understanding of the
United States health system at large, at the associated hospital system in which the
project was implemented, and the available resources for and needs of the HF patient.
This understanding is grounded in the AACN essentials for the DNP prepared
professional including essential II, to develop organizational system changes for quality
improvement in healthcare delivery in response to local and/or global needs and essential
III which includes improving clinical scholarship and analytical methods while
integrating bio-psychosocial, nursing and health theories, research, and evidence-based
practice that exemplifies professional nursing standards (Association of Colleges of
Nursing , 2006).
Evaluation of Practitioner Growth
This project has helped me to increase the scope of my understanding regarding
the care of the HF patient and provided motivation to become involved in other aspects of
nursing practice. I now have the increased desire to become involved in hospital-based
committees that benefit the in-patient population and out patient population while
increasing my understanding of the symbiotic relationship between the two, and plan to
remain current as to developments impacting patient care and reimbursement. It also has
promoted my understanding of the value of and development of professional association
between nursing leaders and facilitated my involvement with a personal network of
advanced practice nurses who remain actively committed to system change and patient
care improvement. It provided the stimulus to change my thinking from an isolated,
independent practitioner, to a member of a team promoting common goals.
Evaluation as Project Developer
The essentials of successful project development include having a research
strategy, finding and selecting appropriate tools, retrieving sources, examining,
understanding, and evaluating research, proper documentation of sources, and
understanding social and systems issues (Zaccagnini & Waud White, 2011). I have
utilized these skills throughout the development of this project; however, I will need
further practice and efforts at developing these skills, in particular the development of an
appropriate intervention strategy as a necessary component of project planning and
implementation (Kettner, Moroney, & Martin, 2008). These skills include techniques to
engage stakeholders, which is a skill that I need to refine. While I had some success at the
development of an implementation strategy, further experience and skill utilizing
techniques to encourage participation is needed. The TRA and TBA were utilized to
attempt to understand motivating factors for stakeholders involved (Azjen, 2014). This
was effective with the nursing staff and two of the providers. Further understanding of
methods to promote involvement is needed to ensure success of future programs.
Understanding the various methods of needs assessment and the interpretation of
those findings contributes to the project success (Kettner, Moroney, & Martin, 2008). A
firm grasp of the importance and methods of needs assessment was gained during the
undertaking of this project including the needs of the individual clinic, the associated
hospital system, and the community. All of these areas were considered when developing
this project. More practice with project planning, development, and implementation is
needed to refine these skills. Additionally, further development is needed to understand
the hospital specific budgeting process and documentation requirements for garnering
approval for new project implementation.
Future Professional Development Related to the HF Project
Innovation and change management of practice and healthcare delivery should be
goals for the future (Bevan, 2010).To continue professional development related to the
project to improve outpatient care of the HF patient, the next step is to disseminate the
findings and utilize them to improve HF patient care beyond the scope of the individual
cardiology practice. Efforts to establish an outpatient disease management clinic caring
for the HF patient at the associated hospital will continue. Two physician champions have
been identified and an interdisciplinary team has been developed. Additionally plans to
increase my understanding and expertise in caring for the HF patient include attendance
at specialty meetings and pursuit of certification in HF nursing. Future classes related to
grant writing are being considered to improve my ability to fund and promote community
The preparation of the DNP project required a systematic investigation of a
practice issue with a possible outcome to effect a system change (Zaccagnini & Waud
White, 2011). The project to improve the outpatient care of the HF patient was developed
as a process improvement project and focused on care improvement at a specific
cardiology clinic associated with a for-profit hospital system. The interest began with the
realization that this hospital had suffered a significant financial penalty in 2013 based on
the readmission of HF patients to the hospital.
The undertaking of this project required a needs assessment, team development,
process and pathway development, integration with the EMR, utilization of statistical
analysis, and understanding of human nature. The logic model provided a framework that
allowed for ongoing evaluation and adjustment to the process during development and
implementation based on feedback from the team members (Department of Health and
Human Services, 2006; Knowlton & Phillips, 2013). The theory of reasoned action and
planned behavior were utilized to help motivate stakeholders (Azjen, 2014). Evidencebased practice guideline and GDMT are well established as methods for the treatment
and management of HF patients (ACCF/AHA, 2013; Fonarow et al., 2008; Hauptman et
al., 2008) and were utilized as the basis for the pathway intervention. Clinical pathways
are an established way to translate and integrate research (Ranjan, Tarigopula, Srivastava,
Obasanjo, & Obah, 2003) and were utilized to coordinate care. The EMR was utilized to
store the HF specific documentation on each patient.
While participation by providers in this project was not what was hoped for, the
nursing staff was educated on HF care, teamwork was established, and improvement in
the care process was initiated. The groundwork has been established for the further
development of improving HF care in the outpatient clinic at this facility and plans for a
formal outpatient heart failure clinic are being considered. It is in this area that the HF
pathway may be fully utilized and tested. All of this experience has provided a growth
opportunity as a scholar, practitioner, project developer, and leader in the health care
system, while paving the way for further improvements for the health of the community.
Chapter 5 is a project evaluation report that will review project goals, project outcomes,
areas for further study, and plans for dissemination.
Chapter 5: Project Evaluation Report
In 2011 approximately 5.8 million Americans had a diagnosis of HF, and it is
estimated that half of the people diagnosed with HF will die within 5 years of diagnosis
with a cost to the healthcare system of approximately 34 million dollars annually,
including the cost of treatment and disability losses (Center for Disease Control and
Prevention, 2013). A problem exists with the continued care of the HF patient after
hospital stabilization and hospital discharge. HF is the cause of 12-15 million office visits
and 6.5 million hospital days annually, with the prevalence rising, and expectations that it
will continue to do so as the elderly population increases, with the aging of 78 million
baby boomers, resulting in 1 in 5 Americans expected to be over the age of 65 by 2050
Data shows that care of the HF patient is frequently fragmented and hospital
readmissions may be prevented with more structured follow up care (Kay et al., 2006)
Well-established evidence-based, guideline directed medical therapy (GDMT)
recommendations exists for the care of the HF patient, which includes outpatient care
(ACCF/AHA, 2013; Hauptman et al., 2008; Mant, Al-Mohammad, Swan, & Laramee,
2011). The challenge to providers has been to put these GDMT to use (Yancy, Krunholz,
& Ryan, 2013). Utilizing clinical pathways to guide care can help to integrate evidencebased, guideline-directed, medical care and have been shown to improve care and
decrease in hospital length of stay (Ranjan, Tarigopula, Srivastava, Obasanjo, & Obah,
2003). These tools used in the outpatient setting can help to coordinate care and promote
appropriate therapy and follow up.
The primary goal of the project was to improve the process of care for the HF patient
in the outpatient clinic through promotion of standardized continuity and consistency of
â€¢ developing a method to promote utilization of evidence-based, GDMT, in the
outpatient clinic for care of the HF patient utilizing a clinical pathway to instruct
nurses and providers and guide care of the HF patient;
â€¢ promoting multi-disciplinary team collaboration;
â€¢ instituting practice change and improvement in documentation; and
â€¢ improving care of the HF patient in the outpatient clinic.
Patient specific data regarding blood pressure, heart rate, arrhythmia, weight,
symptoms, medication adherence and life-style adherence was not evaluated for the
purposes of this study. The study purpose was to analyze the implementation process and
team collaboration and assess provider utilization of the pathway. Also to assess the
frequency with which GDMT and documentation was performed and expose any
deficiencies in recommended care based on EBP guidelines (American College of
Cardiology Foundation/American Heart Association, 2013).This data is intended to be
used as the basis for needs assessment for a nurse-led outpatient HF clinic.
The data was collected regarding eligible patients enrolled on the pathway,
provider utilization of the pathway, and utilization based on the week of implementation.
Documentation in the EMR was facilitated utilizing a HF specific flow sheet regarding
ACE-I use, b-blocker use, documentation of NYHA functional class, documentation of
EF, follow up appointments, and advanced directives. The data on frequencies and
correlations was analyzed using SPSS 21 (IBM, 2013).
The first and second goals were achieved by developing a HF specific clinical
pathway for utilization at the cardiology clinic. The pathway included recommended
assessments, GDMT, follow up recommendations, and documentation recommendations.
The third goal was met through the development of a core team consisting of clerical
staff, nursing, and providers. All office personnel were instructed in the pathway
implementation and utilization. The pathway was initiated on 50% of the eligible patients
during the implementation time. The fourth goal was partially met. Beginning changes in
practice were documented with increased utilization of the clinical pathway as the study
period progressed. While a majority of the patients had documentation of ACE-I use
(80%), b-blocker use (95%), and EF (98%), areas in need for improvement were
revealed. The documentation of advanced directives was found to be rarely performed
(6%), NYHA functional class was inconsistently documented (44%), HF specific
teaching was not consistently performed (23%), and follow up contacts were
inconsistently scheduled (19%).The final goal to improve the care of the HF patient in the
outpatient clinic was partially met with the institution of the care pathway, tool for
documentation in the EMR, and documentation of areas of care in need of improvement.
The beginning process for development of a system wide outpatient HF clinic which
would be available to all patients has been initiated.
Areas for Further Study
Additional investigation into methods to incorporate the pathway seamlessly into
the EMR is recommended. This may facilitate pathway utilization. Also, investigation
into reasoning for limited pathway use by some providers is needed. While the pathway
utilization by the MD providers was supported by nursing staff for data entry, the nurse
practitioners were responsible for entering the HF flow sheet, which signaled pathway
utilization, without assistance from the nursing staff. This may account for the lack of
utilization by two of the three nurse practitioners. Understanding the barriers to
implementation and eliciting provider specific recommendations may help to promote
utilization. Another area for investigation is to understand the reason for the inconsistent
documentation of the NYHA functional class. If the deficiency is caused by a lack of
understanding of the utility of this documentation, further instruction may be needed. If
the problem lies with the ease of documentation in the EMR, potential solutions such as
adding a check box to document the functional class level in the patient review of system
may be beneficial.
Inconsistencies in HF specific teaching occurred in patients on and off the
pathway. Understanding the reason for this lack of documentation may lead to potential
solutions. If the education is being done but not documented, perhaps changes can be
made to the EMR to facilitate documentation. If the issue is lack of time by the provider
during visits, other teaching methods should be considered including; group class,
multimedia, waiting room television instruction or referral to cardiac rehabilitation.
There was limited utilization of patient contact via nurse telephone call after
office visit on patients on the pathway (n=12). Phone contact to patients has been shown
to decrease unscheduled office visits and prevent emergency room visits (Quaglietti,
Atwood, Ackerman, & Froelicher, 2000). Reinforcing the utility of this process of phone
contact and triage may be needed to help increase utilization of this activity. Lack of
familiarity with this service by provides may have prevented the utilization of it.
Finally, advanced directives were documented very rarely. Only six of the 80
patients had advanced directives documented, three patients were on the pathway and
three patients were not on the pathway. The underlying reason for this is unclear. The
social history data entry in the EMR, in which the advanced directives is documented, is
a function entered in the EMR by the nurse or medical assistant. Lack of attention to this
detail may be an oversight or related to the providers underlying feelings regarding
palliatives care or a misunderstanding of the functions and services considered part of
palliative care. Additionally, discomfort with these types of conversations with patients
and families may be at the root of the deficiency in approaching these discussions.
Further investigation into the cause of this documentation deficiency is needed to fully
understand the motivation of the providers and improve compliance with this important
aspect of HF care. This study suggests that teaching opportunities exist regarding current
recommendations regarding advanced directive wishes and palliative care.
Overall this process improvement project was a successful beginning to
improving the outpatient care of the HF patient at this cardiology clinic. The project
utilized a clinical pathway based on EBP and GDMT to create a method to standardize
care for HF patients at this clinic. The pathway was utilized as an educational and
reference tool for the nurses when caring for the HF patient. During the course of the
project implementation, interdisciplinary collaboration and teamwork helped to promote
and refine the process. Additionally, a HF specific flow sheet was utilized in the EMR to
facilitate information transfer to other providers. Areas of documentation deficiency need
for care improvement, and potential for further research were revealed during this study.
Because of this project, steps are being taken to develop a nurse-led outpatient HF clinic
that will serve the hospital and community.
Plans for Dissemination
Dissemination of the HF process improvement project results will begin by
presenting the information to the hospital HF care improvement team and the readmission
prevention team. These teams are members of hospital administration including the chief
executive officer, chief financial officer, chief nursing officer, director of the department
of emergency medicine and director of cardiovascular services. In order to further
disseminate the results of this project to nurses caring for HF patients, a program
evaluation report has been submitted to the American Association of Heart Failure
Nurses for consideration as part of future symposium content. This is an appropriate
forum for presentation of this projectâ€™s outcomes as this organization specializes in
educating nurses in all aspects of HF care.
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Appendix A: Heart Failure Logic Model
â€¢ team collaboration
â€¢ Patient enrollment and
Clinical pathway use
â€¢ Utilization of pathways by
nursing and providers
â€¢ Education of patients
â€¢ Utilization of HF
â€¢ Nurse-led HF clinic
â€¢ Impoved continuity of
â€¢ Increased patient
â€¢ Decreased HF
â€¢ Improved quality of
â€¢ HF care improvement team
â€¢ Out patient providers
â€¢ HF patients
â€¢ create outpatient clinical
â€¢ Train healthcare staff in clinical
â€¢ educate patients
â€¢ Promote utilization of NYHA
functional class in
â€¢ Continuity of HF care through
care based on EBP guidelines
â€¢ Increased understanding of
â€¢ Increase patient understanding
of treatment regime, disease
process, and follow up care
The incidence of HF is increasing, causing increased stress on patients and the
1. Exacerbation of HF is caused by inconsistent treatment, follow up, and knowledge deficit.
2. Providing standard guidelines for care will result in more consistent care of HF patients.
3. Patient education and monitoring will lead to decreased: exacerbation of HF, hospitalizations, cost,
burden on the healthcare system, and improved patient quality of life.
Appendix B: Timeline
Planning &Improvement Team 1-12
Wk 1: Initial team meeting
circulation of teaching content,
tools, and clinical pathway.
Discussion regarding usage of
NYHA functional class on all HF
patients. Begin patient visits and
Wk 2: team meeting: clinical
group, discussion of suggested
revisions, roles, teaching content,
Wk 4: review of first contacts &
areas for improvement
Implementation WK 4-6
Wk 4-6: continued contact and
education of target patients ,
data collection re sx,
education, contacts & follow
Wk 6: team meeting to discuss
progress and problems
Wk 6-10: collect and evaluate
Wk 9-12: prepare overveiw &
evaluation of process Final paper
Wk 12: team meeting to review
process and suggestions for
Dissemination of results to
Hospital QI meeting, and with
Physician Practice Director &
CV Services PR liason with
proposal for HF clinic will be
done at a later date
Appendix C: HF EMR Flow sheet
Appendix D: Pathways
â€¢ Initiate data collection tool. VS, orthostatic BP, wt.
document alcohol use, smoking, PMH
â€¢ Medications including OTC, collect recent lab tests and
diagnositics, EKG if ordered
â€¢Record data from fluid status monitor during visit and remotely
â€¢Notify of any immediate status change or increased arrythmia
â€¢ Establish HF cause (HFrEF, HFpEF, CM etiology)
â€¢ Add HF core measures to EMR, Review and update CHF flow
â€¢ Complete H/P, NYHA functional class, evaluate/ order labs:
BMP, BNP, LFT’s, CXR if indicated, echo (if none in past 12
month or status change) Evaluate medications & device
â€¢ Assess comorbidity status (Arrythmias,HTN, COPD, DM,
thyroid disease, CAD, obesity, smoking)
â€¢ Initiate or titrate GDMT per recommendations
â€¢ Assess learning needs, initiate education plan, prescribe diet
and exercise,establish goals, schedule follow up for 2 weeks
or sooner, schedule education f/u as indicated. Consider
â€¢ Refer to PCP or general cardiologist for management of
comorbid conditions as indicated
Initial HF Care Visit
NP or RN
â€¢VS, orthostatic BP, wt. document alcohol use, smoking, Reveiw
meds. including OTC, reveiw recent lab tests and diagnositics,
EKG if ordered
â€¢Teaching on educational content
â€¢Complete & update CHF flow sheet, assess further learning
needs, schedule f/u education
â€¢interrogated ICD,CRT,CRT-D/ICD if indicated
â€¢record data from fluid status monitor during visit and remotely
â€¢notify of any immediate status change or increased arrythmia
NP or Physician
â€¢Review and update core measures (under quality tab) and CHF
â€¢review test results, titrate medications, order neccesary testing,
schedule follow up
â€¢schedule follow up in 2 weeks or sooner if medication changes, or
3 months if stable and goals met
Follow Up Visit
Class IV with frequent hospitalization
all above consider home inotropes consider palliative care
NYHA Class III-IV
all of previous aldosterone antagonist
CRT/CRT-D if not already in
NYHA Class II
ACE-I titrate slowly, monitor BP&
Creat, doc. contraindications
B-blocker, (esp. with LVSD or
tachycardia) titrate to target dose or
ACE-I (first line)
Lisinopril 2.5-5 mg: target 20 mg Ramipril 1.25 mg-2.5 mg: target 10 mg
Enalapril 2.5-5 mg: target 10 mg bid Captopril 6.25 mg: target 50 mg tid
Fosinopril 5-10 mg: target 20 mg QD
Carvedilol 3.125 mg bid :target 25 mg bid or 50 mg bid if > 85 kg
Metoprolol succinate 12.5- 25 mg QD: target 200 mg QD
Bisoprolol 1.25 mg-5 mg QD (titrate slowly)
Furosemide 40-240 mg 3-4 X/day Bumetanide .5-4mg 2-3 X/day
Toresemide 5-100 mg 1-2 X/day Metalazone 2.5-5 mg 30 min prediuretic
(Avoid if K >5.0 &/or creat >2.5)
Aldactone 12.5-25 mg, increase to 25-50 mg qd
Eplerereone 25 mg target 25-50 mg qd
ARB (if intolerant of ACE-I)
Losartan 25 mg target 25-100 mg 1/day
Valsartan 40 mg target 40-160 mg 2/day
Candesartan 4-8 mg target 8-32 mg 1/day
Patricia L. Dunn, RN,DNP, FNP-BC
4/2007 â€“ present Heart Rhythm Associates of Brevard Rockledge, FL
Care of the patient with complex arrhythmias and cardiomyopathy
Care of patients with devices implanted for cardiac rhythm disturbance
Care of patients with heart failure
1/17/2006- 3/30/07 House Calls of Central Florida Rockledge, FL
Home visits to homebound patients
ALF and SNF rounds
1/2005- 4/2006 Dr. Felix Sosa, MD Cocoa, FL
Care of patients at Internal medicine clinic including, health promotion
And disease management for the adult patient
9/2001- 5/2004 Sanabria and Sims, MD, PS Rockledge, FL
All aspects of care for the pre and post
Cardiothoracic surgery patient
6/2013-112014 Walden University Baltimore, MD
Doctor of Nursing Practice
8/1997-12/1999 University of Central FL Orlando, FL
MSN – ARNP/Family Nurse Practitioner
BSN University of Central FL
Diploma in Nursing St. Lukeâ€™s Hospital School of Nursing Bethlehem,
References are available on request.
American Academy of Nurse Practitioners
American Association of Heat Failure Nurses
Florida Nurse Practitioner Association
Space Coast Clinicians
American Association of Critical Care Nurses 1994-2002
Sigma Theta Tau National Honor Society 1998-2004
Publications, Accomplishments, and Contributions
Thesis Author: The Perceived Quality of Life and Functional Outcome of the Octogenarian
Following Open Heart Surgery
Development of learning modules: â€œCare of the Carotid Endarterectomy Patientâ€, â€œCare of the
Coronary Artery Stent Patientâ€, â€œCare of the Open Heart Surgery Patientâ€
Development of the Progressive Care Nursing Orientation Manual
Presenter Wuesthoff Health Systems Critical Care Course 2000-2003
American Heart Association Community Board Member 20032004
Basic Life Support Instructor 1996-2002
American Cancer Society Triple Touch Instructor 1998-2004
Co-team leader Open Heart Surgery Outcome Team (Sterling Award nominee 1994)
Current: Board Member, Community Treatment Center Board of Directors, Cocoa Florida
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Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.
3. Track the progress
You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.
4. Download the paper
The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.
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