EDUCATI ONAL SETTI NGS I N THE MANAGEMENT OF PATI ENTS W I TH HEART FAI LURE
Gr aziella Badin Alit i1 En eida Rej an e Rabelo2 Fer n an da Ban deir a Dom in gu es3 Nadine Clausell4
Alit i GB, Rabelo ER, Dom ingues FB, Clausell N. Educat ional set t ings in t he m anagem ent of pat ient s w it h heart failur e. Rev Lat ino- am Enfer m agem 2007 m ar ço- abr il; 15( 2) : 344- 9.
Con g est iv e h ear t f ailu r e ( CHF) p r esen t s, b esid es t h e m ag n it u d e of ep id em iolog ical d at a, r elev an t ch ar act er ist ics, in clu din g f r equ en t h ospit alizat ion s cau sed by sev er e sign s an d sy m pt om s, w h ich sh ou ld be st udied t o r educe t he negat ive im pact of t he disease on t he public healt h syst em . Wit h t he advent of sever al clinical t rials in t he area of CHF, t he t reat m ent has becom e m ore com plex, wit h t he need of a m ore organized st r u ct u r e t o assist t h ese pat ien t s. Edu cat ion is con sider ed essen t ial t o r edu ce m or bidit y an d m or t alit y . Th e set t ing, t o begin or t o cont inue t he educat ional pr ocess, can be a hospit al ( hospit alizat ion) , out pat ient clinic, hom e, a day- hospit al or yet , a com binat ion of t hese. The m ain researches in t his area recognize and m ot ivat e an invest igat ion of ot her pat hs t o get bet t er result s in t he pharm acological and non- pharm acological t reat m ent s. I n t his st udy w e r ev iew r ecent dat a, appr oaching sev er al educat ional set t ings in t he m anagem ent of pat ient s wit h CHF.
DESCRI PTORS: hear t failur e, congest iv e; nur sing; educat ion, self car e
ESCENARI OS DE EDUCACI ÓN PARA EL MANEJO DE
PACI ENTES CON I NSUFI CI ENCI A CARDI ACA
La i n su f i ci e n ci a ca r d i a ca co n g e st i v a ( I CC) a d e m á s d e l a m a g n i t u d e p i d e m i o l ó g i ca , p r e se n t a car act er íst icas r elevant es, ent r e las que se incluyen hospit alizaciones fr ecuent es debidas a la exacer bación de sig n os y sín t om as, los cu ales d eb en ser am p liam en t e ab or d ad os p ar a r ed u cir el im p act o n eg at iv o d e la enfer m edad en el sist em a público de salud. Con la apar ición de nuevos ensayos clínicos en el ár ea de I CC, el t r at am ien t o p asó a ser m ás com p lej o, su r g ien d o la n ecesid ad d e u n a est r u ct u r a m ás or g an izad a p ar a la at en ción de los pacien t es afect ados. En est e con t ex t o, la edu cación es con sider ada esen cial par a r edu cir la m orbim ort alidad, siendo el escenario ideal para dar cont inuidad en el proceso educat ivo, el am bient e hospit alario ( int ernación) , el am bient e de am bulat orio, el dom iciliar, en la rut ina diaria del hospit al, o en la com binación de ést os. I nv est igador es del ár ea r econocen y est im ulan a la inv est igación, de t al m odo que sea posible m ej or ar los r esult ados en el t r at am ient o far m acológico y no- far m acológico. En est e ar t ículo r ev isar em os infor m ación cont em por ánea, abor dando los div er sos escenar ios de educación par a el m anej o del pacient es con I CC. DESCRI PTORES: in su ficien cia car diaca con gest iv a; en fer m er ía; edu cación ; au t ocu idado
CENÁRI OS DE EDUCAÇÃO PARA O MANEJO DE
PACI ENTES COM I NSUFI CI ÊNCI A CARDÍ ACA
A insuficiência car díaca congest iv a ( I CC) apr esent a, além da m agnit ude dos dados epidem iológicos, car act er íst icas r elev ant es, incluindo hospit alizações fr eqüent es dev idas à ex acer bação dos sinais e sint om as, q u e d ev em ser m ais am p lam en t e ab or d ad os p ar a r ed u zir o im p act o n eg at iv o d a d oen ça sob r e o sist em a público de saúde. Com o advent o dos vár ios ensaios clínicos na ár ea de I CC, o t r at am ent o da doença passou a ser m ais com plex o, n ecessit an do de u m a est r u t u r a or gan izada par a o at en dim en t o de pacien t es por ela acom et idos. A educação, nesse cont ex t o, é consider ada essencial par a r eduzir a m or bim or t alidade. O cenár io, para o início ou a cont inuidade do processo educat ivo, pode ser hospit alar ( int ernação) , am bulat orial, dom iciliar, h o sp i t al - d i a o u , ai n d a, ser u m a co m b i n ação d esses am b i en t es. Os p r i n ci p ai s p esq u i sad o r es n essa ár ea r econ h ecem e est im u lam a in v est ig ação d e ou t r os cam in h os, q u e m elh or em os r esu lt ad os n o t r at am en t o far m acológico e não- far m acológico. Nest e ar t igo, r ev isar em os dados cont em por âneos, abor dando os div er sos cenár ios da educação par a o m anej o de pacient es com I CC.
DESCRI TORES: in su ficiên cia car díaca con gest iv a; en fer m agem ; edu cação; au t ocu idado
1 RN, M. Sc. Cardiology Sciences; 2 PhD in Biological Sciences, Nursing Coordinat or, Adj unct Professor at Federal Universit y of Rio Grande do Sul, College of
Nur sing; 3 RN, M. Sc. Car diology Sciences; 4 PhD in Car diology, Adj unct Pr ofessor Federal Univ ersity of Rio Gr ande do Sul Medical School, e- m ail: clausell@port oweb.com .br. Cardiac I nsufficiency Clinic of t he Hospit al de Clínicas of Port o Alegre
I NTRODUCTI ON
H
e a r t f a i l u r e ( H F) i s a c h r o n i c a n d p r o g r e s s i v e c l i n i c a l s y n d r o m e t h a t i m p o s e s a nim por t ant funct ional lim it at ion, affect ing t he qualit y
of lif e. I t f r eq u en t ly occu r s in p at ien t s w it h ot h er
diseases( 1). HF is consider ed a public healt h pr oblem
w o r l d w i d e . I n t h e l a s t t h r e e d e c a d e s , b o t h H F
in ciden ce an d pr ev alen ce h av e in cr eased. Wit h t h e
ex t ended life ex pect ancy, est im at es suggest t hat in
2025 Br azil w ill hav e t he six t h highest populat ion of
elder ly people and t hat HF w ill be t he fir st cause of
deat h due t o car diovascular disease in t he w or ld( 2).
Fr eq u en t h osp it alizat ion s p r ov ok ed b y t h e
aggr av at ion of HF signs and sy m pt om s const it ut e a
challenge t o t he m anagem ent of pat ient s. Lit er at ur e
d at a sh o w h i g h r ead m i ssi o n r at es i n t h e f i r st si x
m on t h s af t er disch ar ge f r om t h e h ospit al, w it h t h e
f ir st 3 0 - 9 0 day s bein g con sider ed t h e m ost cr it ical
per iod, w it h r eadm ission r at es r anging fr om 29% t o
47% , w hich incr eases cost s of t he healt h sy st em( 1 ).
Based on t his scenario, innum erous st udies have been
developed, invest igat ing causes and fact ors t hat seem
t o be sim ilar in several count ries( 3).
I n a p r osp ect iv e st u d y w it h 1 0 1 p at ien t s,
d e f i ci e n t a d h e si o n t o p h a r m a co l o g i ca l a n d n o n
-ph ar m acological t r eat m en t w as iden t ified as on e of
t h e m ost f r equ en t r eadm ission f act or s. Am on g t h e
r eadm it t ed pat ient s ( 64% ) , 22% pr esent ed deficient
adhesion t o diet , 37% t o bot h diet and drug ut ilizat ion
a n d 6 % n o n - u t i l i za t i o n o r i r r e g u l a r u t i l i za t i o n o f
dr u gs( 4 ). Th is w as t h e fir st st u dy sh ow in g t h e n on
-ad h esion as a r e-ad m ission f act or, w h ich w as also
confir m ed lat er by ot her r esear cher s( 1, 5- 6).
Wit h t he advent of various clinical t rials in HF
area, t he t reat m ent of t his disease has becom e m ore
c o m p l e x a n d c o n s e q u e n t l y h a s n e e d e d a m o r e
organized st ruct ure t o t reat t hese pat ient s( 5). Besides
an opt im ized pharm acological t r eat m ent , m ainly w it h
t h e u t ilizat ion of dr u gs t h at br in g at t est ed ben ef it s
against m ort alit y ( inhibit ors of angiot ensin- convert ing
enzym e - ACE and bet a blocker s)( 5), ot her st r at egies
h av e b een est ab lish ed t h r ou g h r an d om ized clin ical
t r i a l s , w i t h m u l t i d i s c i p l i n a r y a p p r o a c h e s i n t h e
invest igat ion of pat ient s wit h HF( 7- 8).
Th e f ir st r an dom ized st u dy addr essin g t h is
a sp e ct a n d p u b l i sh e d i n t h e 1 9 9 0 s i n cl u d e d 2 8 2
p at ien t s. Th e in t er v en t ion g r ou p ( n = 1 4 2 ) r eceiv ed
int ensiv e educat ion on HF fr om t he nur se. The m ain
an aly zed ou t com e w as su r v iv al f r ee f r om 9 0 d ay
-readm issions. Alt hough wit hout st at ist ical significance,
i n t e r v e n t i o n p r o m o t e d i m p r o v e d s u r v i v a l f r o m
r e a d m i s s i o n i n t h e a c t i v e g r o u p . I n a d d i t i o n ,
readm issions for any reason, cost s and qualit y of life
w e r e s i g n i f i c a n t l y i m p r o v e d i n t h e i n t e r v e n t i o n
g r o u p( 1 ). A f t e r t h i s s t u d y, m u l t i d i s c i p l i n a r y
int er v ent ions hav e been br oadened int o t he field of
research invest igat ion in pat ient s wit h HF( 7).
To confir m t his r esult , a r ecent sub- analy sis
of CHARM ( Candesart an in Heart failure: Assessm ent
o f Re d u c t i o n i n Mo r t a l i t y a n d Mo r b i d i t y ) s t u d y
d e m o n s t r a t e d t h a t , r e g a r d l e s s o f t h e a d o p t e d
pharm acological t reat m ent - associat ion or not of ACE
inhibit ors wit h angiot ensin recept or ant agonist s - , t he
a d h e s i o n t o t h e a p p r o v e d t r e a t m e n t w a s w h a t
d et er m in ed , in each gr ou p, t h e best m or t alit y an d
m orbidit y out com es in pat ient s wit h HF( 9).
We r ev i ew ed cu r r en t d a t a i n t h i s a r t i cl e,
a d d r e ssi n g v a r i o u s e d u ca t i o n a l sce n a r i o s o f t h e
m an agem en t of pat ien t s w it h h ear t failu r e. For t h e
bibliogr aphical r ev ision, a st udy w as conduct ed w it h
BI REME and MEDLI NE dat abases bet w een 1988 and
2 0 0 5 , u s i n g t h e f o l l o w i n g k e y w o r d s : n u r s i n g ,
congest iv e hear t failur e, self car e and educat ion.
HF SELF CARE EDUCATI ON STRATEGI ES
Healt h educat ion can be defined as a process
t hat im proves t he knowledge and abilit ies influencing
t he pat ient ’s r equir ed at t it udes t o k eep an adequat e
h e a l t h b e h a v i o r. HF e d u ca t i o n , w h i ch i n v o l v e s a
com plex t r eat m ent and alt er at ions t o t he life st y le,
br ings an im por t ant im pact on t he qualit y of life of
t h ose w it h su ch disease, as w ell as t h eir r elat iv es,
r equir ing a per m anent inv est igat ion fr om t he healt h
t eam( 10). The pat ient ’s educat ion provided by t he nurse
follow s t w o dir ect ion s: an in st r u m en t al act ion , t h at
influences t he pat ient ’s at t it ude and behavior ; and a
prot ect ive act ion, wit h t he purpose of m inim izing t he
p at ien t ’s ap p r eh en sion w it h t h e t r eat m en t . I n t h is
pr ocess, t he pr ov ision of infor m at ion ( inst r uct ion) is
essen t ial, b u t it d oes n ot en su r e a ch an g e in t h e
b eh av ior by it self. Th er ef or e, ed u cat ion sh ou ld b e
direct ed t o ‘what t he pat ient needs t o do t o be healt hy’,
scenar io t o st ar t or cont inue t he educat ional pr ocess
m ay b e t h e h o sp i t al ( d u r i n g h o sp i t al i zat i o n ) , t h e
out pat ient clinic envir onm ent , t he pat ient ’s hom e, or
even t he day- hospit al, or a com binat ion of t hem( 3,8,12).
Th e edu cat ion pr ocess can be descr ibed in
f i v e st e p s( 1 3 ), a s f o l l o w s: e v a l u a t i o n o f p r e v i o u s
k n o w l e d g e , co g n i t i o n , a t t i t u d e s, m o t i v a t i o n a n d
m ist ak es t he pat ient s m ak e in t er m s of t heir healt h
t r eat m en t ; iden t if icat ion of w h at sh ou ld be t au gh t ,
consider ing t he pot ent ial lear ning bar r ier s; educat ion
cont ent planning, w it h t he pat ient ’s par t icipat ion t o
d e f i n e i n d i v i d u a l p u r p o s e s a n d s e l e c t t h e b e s t
i n t er v en t i o n s t o ach i ev e t h em ; p l an n i n g h o w t h e
educat ion w ill be int er r upt ed; and finally, a r igor ous
ev aluat ion of t he educat ional pr ocess t hat has been
im p lem en t ed .
How ever, individualizing t he educat ion needs
is not an easy t ask . I n a descr ipt iv e st udy w it h 3 0
pat ient s which evaluat ed t heir m ain educat ional needs,
in t he perspect ive of t he pat ient s t hem selves, doct or
and nur se, t he gr oup of pat ient s list ed t he quest ion
r elat ed t o t he disease k now ledge as being t he m ost
im port ant . On t he ot her hand, t he doct ors list ed issues
r elat ed t o w h at HF is, t h e sy n dr om e pr ogn osis an d
phar m acological t r eat m ent ; and t he nur ses list ed all
opt ions m ent ioned by t he pat ient s and included t he
quest ion “ how will I know when I should see a doct or?”.
The first group at t ribut ed lower priorit y t o t opics such
as diet , exercises and daily w eight verificat ion, w hile
doct ors and nurses select ed us as being of m oderat e
im por t an ce( 1 4 ). Su ch f in din gs con f ir m t h e discu ssed
deficient adhesion t o non- phar m acological t r eat m ent
of HF and reinforce t he need of t he nurse’s act ion in
t he educat ion of t hese indiv iduals.
EDUCATI ON I N HOSPI TAL CONTEXT
Th e st u d ies con d u ct ed in h osp it al con t ex t
t radit ionally em ploy an educat ion plan which is st art ed
d u r i n g t h e h o sp i t a l i za t i o n a n d l a t e r i n v e st i g a t e d
t hrough out pat ient visit s, searching for t he occurrence
of t hose pr ev iously est ablished out com es. I n one of
t he first st udies on healt h educat ion and support , 179
subj ect s hospit alized due t o HF were random ized, and
t he int er v ent ion gr oup ( n= 8 4 ) r eceiv ed, st ill dur ing
t h e h ospit alizat ion , in t en siv e edu cat ion by a n u r se,
besides su bsequ en t in v est igat ion w it h h om e v isit s,
sev en day s aft er t he dischar ge. The r esult s show ed
t hat t he educat ion and support provided by t he nurse
in t he t r ansit ion fr om hospit al t o t he pat ient ’s hom e
significant ly im proved t he self- care pat ient behavior( 7).
An o t h e r s t u d y i n v e s t i g a t e d w h e t h e r t h e
educat ional int ervent ion provided by a specialist nurse,
only dur ing t he hospit alizat ion per iod, w ould r educe
t he rat es of deat h of any nat ure or adm issions, wit hin
a t welve- m ont h invest igat ion period. The int ervent ion
consist ed in t he educat ion on HF and it s t r eat m ent
( d r u g s, d i et , ex er ci ses an d ear l y d eco m p en sat i o n
d e t e c t i o n ) . Th e o b t a i n e d r e s u l t s d e m o n s t r a t e d
r e d u c e d m o r t a l i t y a n d a d m i s s i o n r a t e s , w h e n
com pared t o t he cont rol group( 15).
I n a n o t h e r s t u d y i n c l u d i n g 8 8 p a t i e n t s
ad m it t ed d u e t o HF, t h e ef f ect of t h e ed u cat ion al
int er vent ion w as evaluat ed, w hich st ar t ed dur ing t he
hospit alizat ion and was int ensified aft er t he discharge,
o n r e a d m i s s i o n s a n d / o r m o r t a l i t y a n d H F
hospit alizat ion cost s. The pat ient s w er e allocat ed t o
receive t he educat ion and support int ervent ion ( n= 44)
or r eceiv e t h e st an d ar d h ealt h car e of f er ed b y an
a ssi st a n t d o ct o r ( n = 4 4 ) . Th i s p u r e l y e d u ca t i o n a l
n u r s i n g i n t e r v e n t i o n s t u d y, w i t h o u t a n y o t h e r
m a n a g e m e n t t h a t w o u l d i n v o l v e a n y m e d i c a l
com pon en t , ach iev ed sign if ican t r esu lt s in r edu cin g
r eadm issions, lengt h of st ay and gener at ed sav ings
of US$ 7,515 per pat ient not hospit alized( 16).
The st udies m ent ioned above confirm t he idea
t hat st rat egies involving int ensive and com prehensive
educat ion in issues on HF t r eat m ent ar e essent ial in
an y m an ag em en t p r og r am of t h is sy n d r om e( 5 ). I n
accordance wit h a sequence of various scenarios, from
hospit al car e t o t he out pat ient set t ing, in w hich HF
can be m anaged and suit able t o assess self- care and
educat ion of HF pat ient s, w e w ill nex t r ev iew , som e
st u dies con du ct ed in an en v ir on m en t ch ar act er ized
as int er m ediat e assist ance, t he day - hospit al.
EDUCATI ON I N DAY-HOSPI TAL CONTEXT
Th e day - h ospit al con cept in car diology an d
specifically, in HF, is st ill lit t le explored in bot h nat ional
and int er nat ional lit er at ur e. I t consist s of a for m of
shor t - t er m and int er m ediat e t r eat m ent t o indiv iduals
t hat need daily m edical and nur sing super vision, but
Alt hough t he lit erat ure st ill shows few result s w it h pat ient inv est igat ion on day - hospit al, an I t alian
st u d y co m p a r e d t h e co st / u t i l i t y e f f i ca cy a m o n g subj ect s r andom ized for a m ult idisciplinar y pr ogr am ,
developed at a day- hospit al under t he supervision of a HF clinic ( n= 112) or for a st andard care ( n= 122) in
t h e c o m m u n i t y. Th e h e a l t h e d u c a t i o n a n d r ecom m endat ions w er e pr ov ided by four nur ses and
ot her t eam m em ber s. At t he end of a t w elv e- m ont h
i n v e st i g a t i o n , t h e co n t r o l g r o u p p r e se n t e d m o r e r ead m ission s an d d eat h f r om car d iac cau se w h en
com par ed t o t he day hospit al concept , and t he day -hospit al m odel w as m or e cost effect iv e( 3).
I n t he cur r ent HF cont ex t , t he day - hospit al o p t i o n d e m o n s t r a t e s t h e s i g n i f i c a n t i m p a c t o n
out com es such as r eadm issions, deat h and cost s. I t is st ill n ot clear ly descr ibed an d est ablish ed in t h is
scenario t he role of direct ed educat ion t o pat ient s and
t heir relat ives/ care providers. On t he ot her hand, t he lit erat ure provides abundant publicat ion of art icles t hat
d e m o n s t r a t e t h e n o n - p h a r m a c o l o g i c a l t h e r a p y b e n e f i t s b a se d o n t h e e d u ca t i o n a n d su p p o r t t o
individuals wit h HF, at t he discharge from t he hospit al, i.e., at t he t ransit ion bet ween t he hospit al and ext
ra-hospit al env ir onm ent s( 16).
EDUCATI ON I N EXTRA-HOSPI TAL CONTEXT
Out pat ient Clinic Monit or ing
I n t h e o u t p a t i en t cl i n i c en v i r o n m en t , t h e educat ion process st art s wit h t he det erm inat ion of t he
k now ledge pr ofile on t he hear t failur e issues by t he p a t i e n t s a n d t h e p r a c t i c e d s e l f - c a r e - b a s i c
requirem ent s for t he care t reat m ent . I n a recent st udy conduct ed by our gr oup, w e found r esult s sim ilar t o
t h o se i n t h e l i t er at u r e r eg ar d i n g p at i en t s’ l i m i t ed
knowledge of t he disease and of t he self- care, which ar e aspect s dir ect ly inv olv ed in hospit alizat ions( 17).
I t should be not ed t hat t he out pat ient clinic scen ar io is ap p r op r iat e f or an in t en siv e ed u cat ion
pr ogr am , bot h t o indiv iduals t hat hav e not y et been adm it t ed t o a hospit al due t o HF and t hose w ho ar e
r e t u r n i n g f r o m h o s p i t a l i z a t i o n s d u e t o c l i n i c a l d eco m p en sat i o n . Th e i m p r o v ed k n o w l ed g e o f t h e
p a t i e n t o n se l f - ca r e i s t h e k e y f o r a su cce ssf u l reduct ion in m orbidit y and HF cost s( 7,18). The nursing
int er v ent ions pr ov ided indiv idually should const ant ly
r ein f or ce t h e car e con sid er ed as essen t ial in n on -phar m acological m anagem ent of HF( 17). How ev er, t he
effect iveness of t he int ervent ion will only be achieved when pat ient s wit h HF assim ilat e t he m ain causes of t h e clin ical in st ab ilit y, i. e., u n d er st an d in g t h at t h e pr ev en t ion or t h e ear ly det ect ion of a h y pov olem ic st at us, which provokes increased body weight , edem a for m at ion, dy spnea an d or t hopnea appear ance, can avoid decom pensat ion crises, and consequent ly, visit s t o em er gency or hospit al adm issions( 18).
Ot h er st r at eg ies, su ch as h om e v isit s an d t elephone m onit or ing, focused on t he ex t r a- hospit al educat ion, have also shown sat isfact ory result s in t he m anagem ent of pat ient s wit h HF( 6,12).
Hom e Visit s
Hom e visits are an instrum ent that facilitates the approach of patients and relatives. Through this resource,
we can better understand the fam ily dynam ics and verify t h e f am ily ’s lev el of in v olv em en t in t h e t r eat m en t offered( 19). Com m unit y program s t hat provide prim ary care to people with HF at their own hom e are offered to
those that have conditions to go to a specialized clinic(5). I n t his cont ext of hom e m anagem ent , an invest igat ion w as con du ct ed on t h e h om e in t er v en t ion ef f ect on readm issions and deat h of high- risk pat ient s recent ly
discharged from acut e hospit al t reat m ent . The pat ient s w er e eit her r andom ized t o t he cont r ol gr oup, w hich r eceiv ed st andar d car e ( n= 48) , or t o t he gr oup t hat r eceiv ed h om e car e ( n = 4 9 ) in t h e f ir st w eek af t er
discharge. After a six-m onth investigation period, it was observed a reduction in unplanned readm issions and extra-hospital death in subjects from the intervention group(12). Th u s , h o m e v i s i t h a s s h o w n t o b e a n
innov at ion in healt h ser v ices, an im por t ant st ep for t he dev elopm ent of an effect iv e pr im ar y pr ev ent ion policy. This t ype of care provides an int ense educat ion t o care providers and/ or relat ives, m aking t hem able
and confident t o deliver t he care( 19). Anot her resource t h at is av ailab le f or ex t r a- h osp it al in v est ig at ion of people w it h HF is t he t elephone m onit oring, w hich is pr esen t ed below .
Teleph on e Mon it or in g
Mon it or in g by t eleph on e can be con sider ed
an adj unct m et hod in t he invest igat ion of people wit h HF, if used t o reinforce a plan of care and an educat ional pr ocess, alr eady descr ibed in som e of t he scenar ios. I t is a m et h od u su ally u sed in t h e in v est igat ion of
pat ient s aft er hospit al discharge, and in int ervent ions per for m ed t hr ough hom e v isit s.
Co n s i d e r i n g t h e e f f e c t i v e n e s s a l r e a d y
i n v e s t i g a t e n e w w a y s o f i m p r o v i n g t h e H F
m a n a g e m e n t r e s u l t s , a r a n d o m i z e d s t u d y w a s
d e v e l o p e d t o e v a l u a t e t h e e f f e c t i v e n e s s o f a
st an d ar d ized t elep h on e in t er v en t ion , con cen t r at ed
o n r e d u ci n g t h e u t i l i za t i o n o f h e a l t h r e so u r ce s.
Pat ien t s r ecen t ly disch ar ged f r om h ospit al ( n = 1 3 0 )
w er e al l o cat ed t o t h e i n t er v en t i o n g r o u p an d t h e
in v est ig at ion w as p er f or m ed t h r ou g h st an d ar d ized
t eleph on e calls, accor din g t o a com pu t er pr ogr am .
Th e su bj ect s in t h e con t r ol gr ou p ( n = 2 2 8 ) r eceiv ed
t h e u su al car e of in st r u ct ion b ef or e d isch ar g e an d
in v est igat ion w it h t h eir r espect iv e assist an t doct or s.
Th e i n t e r v e n t i o n g r o u p p r e s e n t e d a s i g n i f i c a n t
r ed u ct ion of HF r ead m ission r at es w h en com p ar ed
t o t h e con t r ol gr ou p, in t h e f ir st t h r ee m on t h s an d
a t t h e en d o f si x m o n t h s. Th e a u t h o r s p o i n t o u t
t h at t h e t elep h on e m on it or in g an d all f or m s of HF
m an agem en t em ph asize t h e cor r ect an d sy st em at ic
u t i l i za t i o n o f a l l p r e scr i b e d d r u g s a n d so l v e a n y
qu est ion s abou t adv er se ef f ect s t h at ar e in cor r ect ly
r e l a t e d t o t h e p h a r m a c o l o g i c a l t r e a t m e n t( 6 ).
L i k e w i s e , a n A m e r i c a n s t u d y , w h i c h i n c l u d e d
sev er al h om e v isit s besides t h e t eleph on e con t act ,
p r esen t ed sim ilar r esu lt s( 1 5 ).
Re se a r ch e r s f r o m Ar g e n t i n a p u b l i sh e d a
r an dom ized clin ical t r ial w it h 1 , 5 1 8 su bj ect s w h ose
purpose was t o det erm ine whet her a t elephone st at ion
of in t er v en t ion s con du ct ed by n u r ses w ou ld r edu ce
t h e in cid en ce of d eat h of an y n at u r e or ad m ission
caused by HF aggr avat ion. The int er vent ion pr oposal
i n cl u d ed i m p r o v ed ad h esi o n t o t h e d i et an d d r u g
t r eat m ent , m onit or ing of sy m pt om s, m ainly dy spnea
and fat igue, cont r ol of w at er ov er load signs t hr ough
t h e w eigh t an d edem a v er if icat ion , an d pr act ice of
physical act ivit y. The result s did not dem onst rat e any
i m p a ct o n m o r t a l i t y, b u t p r e se n t e d a si g n i f i ca n t
r educt ion on r eadm issions due t o HF ( Relat iv e Risk
Red u ct ion = 2 9 % , P= 0 . 0 0 5 )( 2 0 ). Su m m ar izin g , t h e
t e l e p h o n e m o n i t o r i n g p e r f o r m e d a l o n e i s s t i l l
i n s u f f i c i e n t l y s t u d i e d . H o w e v e r, t h e t e l e p h o n e
m o n i t o r i n g a s a n o n - p h a r m a c o l o g i c a l t h e r a p y
com ponent r einfor ces t he int er v ent ion int ensit y and
provides m eans t o m ore efficient and prom pt cont rol
in crit ical sit uat ions and HF aggravat ion.
FUTURE PERSPECTI VES
I n 2 0 0 5 , t h e f ir st sy st em at ic r ev ision w as
p u b l i s h e d t o d e t e r m i n e t h e i m p a c t o f h o s p i t a l
m ult idisciplinary int ervent ions on t he m ain out com es.
Result s show a significant reduct ion in m ort alit y, wit h
r at es sim ilar t o t hose obt ained w it h ACE ut ilizat ion.
The r isk of adm ission of any nat ur e w as r educed by
13% ; t he m ort alit y reduced around 20% ; readm issions
caused by HF were reduced t o 30% ; and, in t en t rials
t hat describe t he m ean hospit alizat ion period ( days) ,
a r e d u c t i o n o f 1 . 9 d a y s w a s o b s e r v e d i n t h e
int er v ent ion gr oup. The st udy show ed t he im pact of
t h e m u l t i d i s c i p l i n a r y m a n a g e m e n t o n t h e m a i n
negat ive out com es of HF and em phasizes t he benefit ,
m ain ly du e t o t h e h om e car e st r at egy, in r edu cin g
r e a d m i s s i o n s o f a n y n a t u r e , o f t h e t e l e p h o n e
m o n i t o r i n g a n d t h e t e l e p h o n e i n v e s t i g a t i o n o n
m ort alit y, in addit ion t o a sim ilar benefit of hom e care
and t elephone int ervent ions relat ive t o adm issions( 21).
The lit er at ur e has alr eady dem onst r at ed t he
benefit s r egar ding t he healt h educat ion and suppor t
int er v ent ions obt ained by m ult idisciplinar y t eam s in
sev er al env ir onm ent s w her e HF can be m anaged( 22).
How ev er, som e quest ions hav e not y et been clear ly
answ ered, as several st udies have found negat ive or
inconclusive result s relat ive t o t he out com es provided
b y ed u cat ion al in t er v en t ion s( 7 ). For in st an ce, w h at
w ould be t he m ost effect iv e educat ion pr ogr am and
w h at sh ou ld be t h e edu cat ion in t en sit y lev el in t h e
invest igat ion of pat ient s wit h HF?
This uncer t ain scenar io encour aged a m ult
i-cen t er st u d y, n a m ed COACH ( Co o r d i n a t i n g st u d y
ev alu at in g Ou t com es of Adv isin g an d Cou n selin g in
Hear t f ailu r e) , w h ich w ill ev alu at e 1 , 0 5 0 su b j ect s
random ized int o 3 groups: a) visit s t o a cardiologist ;
b) basic and support educat ion; and c) int ensive and
support educat ion. The result s of t his st udy m ay help
t he healt h t eam t o select what int ervent ion should be
ad d ed o r r em ov ed f r o m t h e HF m an ag em en t an d
cont r ol pr ogr am s( 22).
FI NAL CONSI DERATI ONS
The com plex it y in m anaging indiv iduals w it h
HF is a challenge for t he healt h t eam involved. I n t his
se n se , t h e n u r se a ct i o n a s i n t e g r a l p a r t o f t h e
m u l t i d i s c i p l i n a r y t e a m s s p e c i a l i z e d i n t h e H F
m anagem ent is essent ial. Fut ur e pr ospect iv e st udies
co u l d e x p l o r e a l t e r n a t i v e a ct i o n s, su ch a s g r o u p
in st r u ct ion , w h ich is an ex am ple of w h at h as been
done in ot her cont ex t s, such as t he diabet ic pat ient
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