Chapter 9Community nursing

• Mortality during study period (CRITICAL)
• Quality of life during study period (CRITICAL)
• Readmission up to 30 days
• Number of admissions to hospital after 28 days of first admission
• Avoidable adverse events during study period (CRITICAL)
• Number of presentations to Emergency Department during study period
• Number of GP presentations during study period
• Length of hospital stay during study period
• Patient and/or carer satisfaction during study period (CRITICAL)

Clinical service organisation for heart failure.

Randomised controlled trials (RCTs) with at least 6 months follow up, comparing disease management interventions specifically. directed at patients with chronic heart failure (CHF) to usual care.

Adults with CHF.

Interventions were classified by: (1) case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); (2) clinic interventions (follow up in a CHF clinic) and (3) multidisciplinary interventions (holistic approach bridging the gap between hospital admission and discharge home delivered by a team).

The components, intensity and duration of the interventions varied, as did the ‘usual care’ comparator provided in different trials.

19 studies from the Cochrane review included in our review

Home care by outreach nursing for chronic obstructive pulmonary disease (COPD).

Randomised controlled trials (RCTs) evaluating the effectiveness of outreach respiratory health care worker programmes for COPD patients in terms of improving lung function, exercise tolerance and health related quality of life of patient and carer, and reducing mortality and medical service utilisation

Studies in which the therapeutic intervention under test was physical training were not included.

5 studies from the Cochrane review included in our review

• Home visits by physicians and nurses, for clinical examination, tests/analyses as required, and adjustment of medication as required (note: this intervention was not HF specific, but was intended to reduce readmissions across a range of medical and surgical conditions).
• Additional nursing staff home visits 2, 5 and 10 days after discharge for education for patients and relatives about HF (basic facts and management, that is, symptoms, life style, diet and therapy)
• Patients received educational manual and a phone number for queries
• Comparator: usual care (referral to primary care physician)

Patient (n= 279) hospitalised for heart failure.

Mean (SD) age: 75.3 (11.1) versus 76.3 (9.4).

Percentage male: 38.7 versus 40.1.

Ethnicity: not stated.

Spain.

In Cochrane review:

Clinical service organisation for heart failure.

Duration of intervention: 15 days.

6 and 12 months follow-up.

• Advanced practice nurse care manager (APN-CM) performed an in-home assessment within 1 week of discharge.
• Standard education and intervention protocols for stroke and common post-stroke complications were implemented during the home visit.
• Results of home assessment were reviewed by an interdisciplinary post-stroke consultation team. (PSC-team)
• PSC-team developed patient care plans specific to each problem identified by the APN-CM.
• Periodic phone calls were used to assess patient changes that warranted further intervention.
• Additional home visits were made on an as-needed basis.

• After discharge the acute stroke unit or short-term rehabilitation, control subjects received usual post-discharge care from their primary care physician.
• No assessments by the research team until after 6-month outcomes were measures.
• Patients received mailings every 2 months reminding them of their involvement in the study and providing stroke-related patient educational materials.

People (n=380) diagnosed with ischemic stroke discharged to home from the acute care hospital, or discharge to home within 8 weeks from a short-term skilled nursing facility (SNF).

Mean age: 68.5 years.

Male percentage: 50%.

Ethnicity: African-American 16%.

USA.

• 1 to 1 single education session for patients and carers prior to discharge and session with primary care physician post discharge to reinforce education.
• teaching brochure to reinforce education, covering: diagnosis of HF, information about the disease (pathogenesis etc.), symptoms of HF, symptoms and signs of worsening HF, what to do if condition worsens, lifestyle advice, medication education for carers.
• cardiologist outpatient clinic every 3 months, including medication review
• patient given specific/tailored self-management plan.
• visit with primary care physician scheduled within 2 weeks of discharge.
• tele-monitoring component -a facilitated telephone monitor (SCT) providing a 24 hour mobile phone contact number which patients were encouraged to contact as necessary. Patients could also telephone the HF team for advice during office hours.

Patients (n=338) with congestive heart failure discharged from cardiology wards of 3 participating hospitals

Median age (IQR) 69 (61-74) in intervention group, 67 (58-74) in usual care group

Male sex (both groups) 203 (60%), (intervention group 101/164, 62%), (control group 102/174, 59%)

Ethnicity: not given

Spain

In Cochrane review:

Clinical service organisation for heart failure.

Median duration of intervention: 509 days (IQR

1 year follow-up.

• Patients in the respiratory home care group received specialised care from trained respiratory nurses at least 1 a month

• Patients in the standard home care group received standard home care from nurses at least once a month

Patients with COPD (n=301). Patients had to have a clinical diagnosis of COPD, be homebound (by US Medicare criteria, for use of public transport), be between 40-75 years of age.

USA

In Cochrane review: Home care by outreach nursing for COPD

The outcomes of the interventions were assessed at 6 and 12 months after enrolment

The duration of the intervention period was 12 months.

• During index hospitalisation: Patients were seen by a HF nurse prior to discharge.
• After discharge: Home visit by HF nurse and within 48 hours of discharge. Subsequent visits by HF nurse at 1, 3, and 6 weeks and at 3, 6, 9 and 12 months. Scheduled phone calls at 2 weeks and at 1, 2, 4, 5, 7, 8, 10 and 11 months after discharge. Additional unscheduled home visits and telephone contacts as required.
• Home visits covered: patient education about HF and its Rx, self-monitoring and management. Patients were given a booklet about HF which included a list of their drugs, contact details for HF nurses, blood test results and clinic appointment times.
• The trained HF nurses used written drug protocols and aimed to optimise patient treatment (drugs, exercise and diet) and HF nurses also provided psychological support to the patient. HF nurses liaised with the cardiology team and other health care and social workers as required.

• “Patients in the usual care group were managed as usual by the admitting physician and, subsequently, general practitioner.
• They were not seen by the specialist nurses after discharge.”

Patients (n=165) admitted as an emergency to the acute medical admissions unit at 1 hospital with HF due to LV systolic dysfunction.

Actual age of study subjects: usual care mean 75.6 years (SD 7.9), intervention 74.4 years (SD 8.6).

Male sex: 58%

Ethnicity: not given.

United Kingdom (Scotland)

In Cochrane review:

Clinical service organisation for heart failure

Duration of intervention: up to 12 months.

12 month follow-up.

Also looked at: admission rates in the moderate risk subgroup compared to the high risk sub group.

• Thirteen experienced and comprehensively trained stroke nurses applied the outreach care program that consisted of 3 nurse-initiated telephone contacts (1 to 4; 4 to 8; and 18 to 24 weeks after discharge) and a visit to the patients in their homes (10 to 14 weeks after discharge).
• During all contacts, the nurses used a standardised checklist on risk factors for stroke, consequences of stroke and unmet needs for stroke services.
• Nurses supported patients and carers according to their individual needs (for example, by giving information or reassurance)

People (n=536) with stroke

Mean age range: 63-66 years.

Male percentage: 49%.

Ethnicity: not stated.

Netherlands.

• During index hospitalisation: cardiac prognostic stratification and prescription of individual tailored therapy following guidelines and evidence.
• After discharge: attendance at day hospital staffed by a multidisciplinary team (cardiologist, nurse, physiotherapist, dietician, psychologist and social assistant). Patient access to the day hospital ’modulated according to demands of care process’. Care plan developed for each patient. Tailored interventions covering: cardiovascular risk stratification; tailored therapy; tailored physical training; counselling; checking clinical stability; correction of risk factors for haemodynamic instability; and health care education. Patients who deteriorate re-entered the day hospital through an open-access programme.
• Day hospital also offered: intravenous therapy; laboratory examinations; and therapeutic changes as required.

• During admission: cardiac prognostic stratification and prescription of individual tailored therapy following guidelines and evidence
• After discharge: ’The patient returned to the community and was followed up by a primary care physician with the support of a cardiologist’.

Patients (n=234) with CHF referred for admission to the Heart Failure Unit at 1 centre or the Heart Transplantation Programme. All had been hospitalised for HF.

Actual age of study subjects: mean age 56 years (SD 10).

Male sex: 84%.

Ethnicity: not given.

Italy.

In Cochrane review:

Clinical service organisation for heart failure.

Duration of intervention: not clear.

Follow-up at 12 months.

• APN recruited and trained the peer advisors and assigned them to patients.
• APN supported patients and peer advisors through 24-hour telephone contact.
• Intervention lasted 12 weeks. APN made a home visit and called 3x during the intervention. Peer advisor made weekly calls to patient.

Older adults (n=247) with a diagnosis of myocardial infarction (MI) or coronary artery bypass surgery (CABS)

Recruited during hospitalisation before discharge after MI and CABS

USA

Not in Cochrane.

Data collection at 6 weeks, 3, 6, and 12 months after MI and CABS. Data reported in paper at 12 months.

Four groups: CI+intervention+SC; CAB+intervention+S; CI+SC; CAB+SC

More about the effect of the peer advisor than the nurse.

• During index hospitalisation patients received an education programme from HF nurse consisting of 2 visits.
• Two weeks after discharge patients and their families were invited to a 1 hour group education session led by the HF nurse and were also offered a 7 day medication dispenser if deemed appropriate.
• Patients were followed up at a nurse directed o/p clinic and there was a single prescheduled visit by the nurse at 8 months after discharge. The HF nurse was available for phone contact during office hours.
• Patients were offered cardiology outpatient visits 1 and 4 months after discharge.
• The inpatient and outpatient education programme covered: HF pathophysiology, pharmacological and non-pharmacological treatment.

• These patients were ”followed up at the outpatient clinic in the department of cardiology by either cardiologists in private practice or by GP”.

Patients (n=190) hospitalised primarily because of heart failure.

Actual age of study subjects: mean 75.6 years (SD 5.3)

Male sex: 53%

Ethnicity: not given

Sweden.

In Cochrane review:

Clinical service organisation for heart failure.

Duration of intervention: 12 months.

1 year follow-up.

• Patients in the medical management group received approximately 8 hours of education about the diagnosis of COPD, the assessment of COPD severity, patient self-management, smoking cessation, follow-up and the formation of an action plan for exacerbations.

• In addition to medical management, patients in the medical and collaborative management group received approximately 8 additional hours of training in ’collaborative care’, intended to facilitate the adoption of healthy behaviours such as lifestyle and self-management skills.

• Patients in the control group continued to receive usual care.

Patients (n=217) with COPD who fulfilled 3 criteria: were a current or former smoker with at least a 20-pack-year smoking history, had at least 1 respiratory symptom (for example,. cough, shortness of breath, wheeze) during the past 12 months, and had demonstrable airflow obstruction (FEV1/FVC ratio < 70% and FEV1 < 80% predicted).

USA.

In Cochrane review: Home care by outreach nursing for COPD.

The outcomes of the interventions were assessed at the end of the 6 month intervention Period.

The duration of the intervention period was 6 months.

• Usual care plus registered nurse-led (and physiotherapist) intervention (exercise intervention, nursing intervention while in hospital.
• Home visits and telephone calls by nurse, assessment of support, progress monitoring).

• One hour educational session with a nurse in the patient’s medical centre.
• Patient received educational materials including methods for self-monitoring symptoms, body weight and medications; a dietary management workbook; food frequency questionnaires. They viewed a video on treatment process, received instructions on how to access emergency care if needed.
• 45 min baseline telephone counselling session within 1 week of randomisation by experienced nurse care manager. Subsequent nurse contacts tailored to meet needs of the patient. Follow up phone calls by nurse to patient weekly for 6 weeks, biweekly for 8 weeks, monthly for 3 months, bimonthly for 6 months.
• Nurse care managers obtained permission from physicians to initiate and regulate pharmacologic therapy for HF according to study protocol. Nurses coordinated treatment plan with patients and physicians.

Patients (n=462) hospitalised with a provisional diagnosis of heart failure in study hospitals as indicated by new onset or worsening heart failure.

Mean age all = 72 year (SD 11)

Ethnicity, n (%):

White 195(86) versus 191(82);

Black 13(5) versus 14(6);

American Indian 9(4) versus 18(8);

Hispanic 7(3) versus 7(3);

Asian 4(2) versus 4(2).

USA.

In Cochrane review:

Clinical service organisation for heart failure.

Duration of intervention: 12 months.

Outcomes reported at 1 year.

• teams included a cardiologist experienced in geriatrics, specialised nurses and the patient’s primary care physician.
• programme components: discharge planning, continuing education, therapy optimisation, improved communication with healthcare providers, early attention to signs and symptoms and flexible diuretic regimes.
• patients given a written list of recommendations, a weight chart, a contact number available 6h/day, and an education booklet.
• follow-up via hospital clinic visits, periodical nurse’s phone calls.
• patients attended heart failure clinics within 7 to 14 days of discharge and at 1, 3 and 6 months thereafter for optimisation of treatment and education.
• primary care physicians assessed adherence to treatment, evaluated adverse effect and co-morbidities, and monitored diet.

• Optimised treatment and standard education. All treatments and services ordered by primary care physician and/or cardiologist. Baseline clinical evaluation and therapeutic plan documented.

Elderly patients (n=184) discharged home after hospitalisation due to heart failure.

Age: Control: 77.5 (SD 5.7), Intervention: 77.4 (SD 5.9)

Percentage male: Control: 52.8, Intervention: 51.2

Ethnicity: not stated.

Italy.

In Cochrane review:

Clinical service organisation for heart failure.

Duration of intervention: 24 months.

Follow-up at 24 months.

• After discharge: Outpatient review at heart failure clinic within 2/52 of discharge from hospital: clinical status reviewed, pharmacological treatment based on evidence based guidelines, one-to-one education with study nurse, education booklet provided.
• Patient diary for daily weights, Rx record & clinical notes provided. Detailed letter faxed to GP and follow up phone call to GP.
• Follow up plan aiming at 6 weekly visits alternating between GP and HF clinic.
• Group education sessions for patients run by cardiologist and study nurse: 2 sessions offered within 6 weeks of discharge and 1 at 6 months post d/c.
• Telephone access to study team for GPs or patients during office hours Group education sessions covered: education about disease; monitoring daily body weight and action plans for weight changes; medication; exercise; diet.

Patients (n=197) admitted to general medical wards with a primary diagnosis of heart failure.

Actual age of study subjects: mean 73 years (SD 10.8, range 34 to 92 years).

Male sex: 60%.

Ethnicity: ’NZ European’ 79%.

New Zealand.

In Cochrane review:

Clinical service organisation for heart failure.

Duration of intervention: 12 months.

Outcomes at 12 months.

• evaluation at clinic within 2 weeks of hospital discharge; rapid access to cardiologists, clinician nurses, dieticians and pharmacists, with access to social workers and other medical specialists as required.
• follow-up phone call from nurse within 72 hours of hospital discharge and then monthly.
• After baseline evaluation, clinic cardiologists individualised treatment plan.
• One-on-one education of the patient and family with the study nurse initiated at first clinic visit (disease process, symptoms and signs of HF, fluid and sodium intake restrictions, body weight monitoring, medications and compliance, recommendations regarding exercise and diet.
• patient diary (for example, daily weight, medication record, clinical notes)
• individualized dietary assessments; pharmacist evaluated medications
• monthly visits with both a cardiologist and nurse at the clinic
• Patients advised to call clinic nurse if symptoms worsened.

Patients (n=230) seen at the emergency department of or admitted to the Montreal Heart Institute with a primary diagnosis of congestive heart failure.

Mean (SD) age: 68 (10)/10 (10)

% male: 83 (73)/82 (71)

ethnicity: not stated.

Canada.

In Cochrane review:

Clinical service organisation for heart failure.

Duration of intervention: 6 months.

Outcomes at 6 months.

Intervention: Home health nurses intervention (telephone and in-home visits over 6 weeks)

Control group: ‘Usual home visits’

Symptom recognition and reporting, education, emotional support

Not in Cochrane.

Control group not in hospital and not specified what ‘usual home visits’ are

Excluded from our HaH classification because control not in-patient

• Nurse case management consisted of coordination and provision of health care services by nurses, both in and out of hospital, for 10 month period.
• Involves access to whole MD team

• Variation by healthcare provider and community health centre (hospital and community services provided separately)

• Visit by nurse and GP. Nurse evaluated discharge plan had been put in place, alter service if needed

• Social and medical support according to prevailing routines

• Usual care plus comprehensive programme, adding supports to improve the transfer from hospital home (for example,. counselling and education, phone outreach, support)

• Completion of medical history, nursing assessment form, MD discharge plan; home nursing care

• Two home visits by a community nurse: detailed assessment of the patient’s health status and respiratory function; education on the disease and advised on stopping smoking (if applicable), management of activities of daily living and energy conservation, exercise, understanding and use of drugs, health maintenance, and early recognition of signs that require medical intervention;
• Referred patients to other services such as home care; care plan posted to the GP
• Patients encouraged to continue to refer to the education booklet for guidance and to keep in contact with their GP for 4 weeks.

• Discharge to GP care with or without specialist follow up; did not include routine nurse or other community follow up.

In Cochrane review: Home care by outreach nursing for COPD

COPD patients did not present with exacerbation

• Nurse-led individualised home-follow up programme with a duration of 1 year
• Intervention programme started with an initial session of 1 hour, taking place shortly before hospital discharge, where patients were provided with information about disease, co-morbidities, and medication.
• Information was given orally and in written form of a so called ‘heart book’.
• After discharge, home visits (up to 4) and telephone calls (at least every 3 months) were carried out according to patient need and risk level. (risk level assessed by study nurse during first home visit)

Older people (n=340) admitted with acute myocardial infarction.

Age (mean ± SD): Intervention 75.2±6.0; Control 75.6±6.0.

Percentage male: 62%

Ethnicity: not stated

Germany

Intervention: ’Supportive educational intervention’

• During index admission: Intensive education by study nurse using standard nursing care plan
• After discharge: Study nurse phoned patient within 1 week of discharge to assess potential problems and made appointment for home visit. At home visit education continued. Between discharge and home visit patient could contact study nurse if they encountered problems.
• After home visit patient encouraged to contact their cardiologist, GP or emergency heart centre with any problems. Educational component covered: symptoms of worsening failure, sodium restriction, fluid balance and compliance and individuals’ problems, and included education and support to patients’ family.

Comparator: Usual care.

• ”A nurse or physician, depending on his or her individual insight into the patients’ questions, provided these patients with education about medication and lifestyle“.
• Usual care patients did not receive structured education

Patients (n=179) admitted to the cardiology unit of 1 hospital with HF symptoms and diagnosis verified with Boston score.

Actual age of study subjects: not given for original group, those who remained at 9 months were mean age 72 years (SD 9) at baseline.

Male sex: of those who remained at 9 months, 60%

Ethnicity: not given

Netherlands

In Cochrane review:

Clinical service organisation for heart failure

Duration of intervention: up to 10 days after discharge from index admission, on average

1 week*

Outcomes reported at 9 months

• During index hospital stay: patient education by HF nurse according to protocol and guidelines, behavioural strategies used to improve adherence
• Within 2/52 of d/c telephone call to pt from HF nurse
• During regular visits to cardiologist at the outpatient clinic (at 2, 6, 12 and 18 months after d/c) additional visits to HF nurse. Additional visits just to the HF nurse at the outpatient clinic at one, 3, 9, & 15 months after d/c. Telephone access to HF nurse Monday to Friday 9am -5pm, patients (and families) encouraged to contact their nurse if any change in their condition or any questions.

• Home visit by HF nurse within 10 days of d/c to assess coping, CHF health status general health, and medical, health care and social support.
• Second home visit 11 months after discharge, Weekly telephone calls by the HF nurse in the first month after discharge then monthly calls. - Out of hours back up to provide 24 hour telephone coverage.
• HF nurse to consults multidisciplinary team at least once during both index admission and once during follow up to optimise her advice for each patient.

Patients (n=1049) admitted to hospital for HF

Age: intensive: 70 (SD 12), basic: 71 (SD 11), control: 72 (SD 11)

Percentage male: intensive: 61, basic: 66, control: 60

Ethnicity: Not stated

Netherlands

In Cochrane review:

Clinical service organisation for heart failure

Duration of intervention: 18 months

• Intervention sought to bridge the gap between hospital and general practice, provide a structured programme of follow-up care, promote adherence to therapies, and to encourage general practice nurses to provide structured follow-up

Not in Cochrane.

RCT but not randomised at the patient level rather GP practices were randomised. Data were first analysed on an individual patient basis.

• During index hospitalisation: CHF cardiologist designed an individualised treatment plan which included medication, diet and exercise management
• After discharge: ’Telephone nurse co-coordinator’ phoned patients within 72 hours of discharge and then weekly for 1st month, bi-weekly in 2nd month and then monthly. Monthly follow up with CHF nurses (usually in CHF clinic).
• ’Primary care physicians’ (66% internal medicine physicians, 29%cardiologists) received regular updates from CHF nurses and were notified of abnormal lab results. All intervention patients received: pill sorter, list correct medications, list of dietary and exercise recommendations, 24 hour telephone contact number and patient educational material. If required and financial resources limited patients also received: 3g sodium ’Meals on
• Wheels’ diet, weigh scale, medications, transport to the clinic and a phone. CHF cardiologist saw patients at 6 months. Content of CHF nurse follow up: aimed to implement the treatment plan designed by CHF cardiologist which included initiation and titration of drugs, a low sodium diet and exercise recommendations

• Usual care by the patients’ primary physicians (73% internal medicine physicians, 26% cardiologists).
• CHF cardiologist designed treatment plan for each patient ”documented in patient’s chart without further intervention“

Patients (n=200) admitted to 1 of 2 hospitals with a primary diagnosis of CHF

Actual age of study subjects at recruitment: median 63.5 years (range 25-88 years)

Male sex: 61%

Ethnicity: ’white’ 64%

USA

In Cochrane review:

Clinical service organisation for heart failure

Duration of intervention: 6 months.

Outcomes at 6 month reported

• Home visit from nurse-manager within 3 days of discharge, focusing on dietary and medical compliance, daily weights, self-monitoring, and early reporting of changes in weight or clinical status.
• Teaching tool ’Patient and Family Handbook’ given to patients during home visit, including sections on HF (definition), medications, low-salt diet, importance of daily weight, and clinical signs and symptoms that should prompt a call to the SPAN-CHF
• nurse or primary care physician (plus contact phone numbers).
• During home visit, nurse performed cardiovascular examination and symptom assessment. Weekly or biweekly phone calls from nurse-manager to patients focused on
• identifying changes in clinical condition and education reinforcement.
• Patients had 24-hr 7-day telephone access to nurse managers, and were instructed to report changes in clinical status and relevant weight change. Frequent communication between nurse-managers, primary care physicians and HF specialist.

Patients (n=200) were enrolled during an index HF hospitalisation or within 2 weeks of discharge.

Age: Control: 73.9 (SD 10.7), Intervention 70.3 (SD 12.2)

Percentage male: Control: 58.3, Intervention: 57.7

Ethnicity: Not stated

USA

In Cochrane review:

Clinical service organisation for heart failure

Duration of intervention: 90 days, followed by passive surveillance (nurse-manager available for incoming calls but didn’t make scheduled calls) for clinically stable patients or continuation for patients with overt clinical instability (class A)

• Early discharge plus follow-ups by the APN initially face-to-face, later by telephone, for patient education, medication, facilitation of discharge planning, raising awareness of follow-up appointments and outpatient tests.

• Discharge planning and follow-up were left to the treating physician and nursing team; no added nursing intervention

Intervention: ’Education and Support’

• After discharge: Initial hour long face to face consultation with experienced cardiac nurse within 2 weeks of discharge using a teaching booklet.
• Following this weekly telephone contact for 4 weeks, bi-weekly for 8 weeks then monthly until 1 year.
• Initial consultation covered: patient knowledge of illness; the relation between medication and illness; health behaviours and illness; knowledge of early signs and symptoms of decompensation, where and when to obtain assistance.
• Follow up phone calls reinforced these domains. However the nurse could recommend that the patient consulted his/her physician when the patient’s condition deteriorated sharply or when the patient had problems, in order to help patients to understand when and how to seek and access care

All usual care treatments and services ordered by their physicians

Patients (n=88) hospitalised for HF; needed to have either admission diagnosis of heart failure or radiological signs of heart failure on admission chest x-ray.

Actual age of study subjects: median age 74 years, controls mean age 71.6 (SD 10.3), intervention 75.9 (SD 8.7)

Males: 57%

Ethnicity: ’74% Caucasians’

USA

In Cochrane review:

Clinical service organisation for heart failure

12 month follow-up

Duration of intervention: 1 year

• Usual follow-up plus home visits by community nurse proving counselling (for example,. drug compliance, dietary advice), checking vital signs, and medications.
• Nurse access also via pager. Nurse closely liaised with geriatrician or cardiologist.

• Usual medical and social care and followed up in hospital outpatient clinics by geriatricians or cardiologists.

Adults (n = 105) >60 years, with chronic heart failure in Hong Kong.

Recruited on the day or the day before hospital discharge

• Usual follow-up plus home visits by community nurse proving counselling (for example,. drug compliance, dietary advice), checking vital signs, medications. Nurse access also via pager. Nurse closely liaised with geriatrician or respiratory physician.

• Usual medical and social care and followed up in hospital outpatient clinics by geriatricians or respiratory physician.

• Once patients were discharged to home, the intervention began as an ambulatory care programme.
• Patients received 1 home visit by a specialised HF nurse approximately 1 week after returning home after discharge from either hospitalisation or rehabilitation
• Followed by 17 telephone calls in decreasing intervals over the next 12 months.
• Home visit consisted of a physical, psychosocial and environmental assessment, the provision of educational, behavioural and supportive care to build self-care abilities and individualised patient goal-setting to increase self-efficacy.
• Following the home visit an individualised nursing care plan was developed that included the patient-identified goals.
• Examined by the study HF-cardiologist who recommended lifestyle modifications to the patients and made suggestions for optimal medical management to the patient’s primary care physician.

• Examined by the study HF-cardiologist who recommended lifestyle modifications to the patients and made suggestions for optimal medical management to the patient’s primary care physician.

People (n=42) with decompensated heart failure (HF)

Age (mean ±SD): 77.0±6.5 years

Percentage male: 62%

Ethnicity: not stated

Switzerland

• Home treatment team (HTT) comprising of nurse manager and health care assistants. Up to 3x daily visits by HTT worker for up to 6 weeks providing personal care, domestic assistance etc.).
• Ward team and nurse manager provided a care plan for each patient. Weekly review of progress.

• ‘appropriate conventional community services’

Not in Cochrane.

12 month trial; clinical assessments at 6 (half sample) and 12 weeks (full sample)

• regular visits to the outpatient clinic and patient encouraged to keep contact with nurse (not clear how regular); nurse checking symptoms and signs of heart failure, blood pressure, heart rate, and weight at each visit
• nurses can institute and change medication doses according to standard protocol
• patient instructed to check weight regularly and monitor early signs of deterioration. Patients with good compliance instructed to change dosing of diuretics on their own.
• dietary advice recommends restricted sodium, fluid, and alcohol intake; information repeated in booklets and computerised educational programmes

• Treated by GPs according to local health care plan for heart failure.
• All patients had clinical examinations and detailed control of medication at 6, 12, and 18 months at the Cardiovascular Research Lab

Patients (n=208) 60 years of age or older hospitalised with heart failure.

Age: Control: 75.7 (SD 6.6), Intervention: 75.9 (SD 7.7)

Percentage male: Control: 59, Intervention: 56

Ethnicity: Not stated

Sweden

In Cochrane review:

Clinical service organisation for heart failure

Duration of intervention: at least 18 months, mean follow up was 1122 (405) days

Outcomes reported at 6 and 12 months (QoL) and 18 months for all

• pre discharge intensive education by an experienced cardiovascular research nurse using a teaching booklet, covering causes of HF, recognition of symptoms of worsening
• HF, the role of sodium restriction and pharmacological therapy, the importance of fluid and weight control, physical activity and complete abstinence from alcohol and smoking.
• phone call from nurse 3-5 days post discharge to assess any problems, promote self-management and check compliance, weight and lifestyle issues. Patients had telephone access from 8.00 to 9.00am, Monday to Friday, and out of hours answering machine.
• outpatient visits to doctor at 15 days, 1 and 6 months after discharge, to evaluate test results, physical condition and medicine adherence and make any required changes to drug therapy

• pre-existing routine of post-discharge care; that is, usual care by GP.
• Outpatient visit to doctor at 6 months post discharge

Elderly patients (n=200) admitted to internal medicine department with a diagnosis of HF during recruitment period

Age: Control: 73 (SD 8), Intervention: 73 (SD 9)

Percentage male: Control: 62, Intervention: 62

Ethnicity: Not stated

Italy

In Cochrane review:

Clinical service organisation for heart failure

Duration of intervention: 6 months

Outcomes reported at 6 months

• assessment by respiratory physician and respiratory nurse; patient-specific care plan was negotiated by GP and practice nurse including regular check-ups, setting goals for lifestyle changes, symptom management, education on smoking cessation, medication.
• Patients visited the practice nurse monthly and GP 3 monthly. They received home visits by respiratory nurse specialist.

• Underwent assessment procedures but received no care plan, were not seen by respiratory physician, did not have access to respiratory nurse specialist.
• GPs had access to COPD management guidelines

• General advice from ward-based staff, outpatient clinic follow-up as necessary and access to the local cardiac rehabilitation programme offered as per usual practice.
• People received at least 2 home visits after hospital discharge by a cardiac support nurse. These were 1-2 and 6-8 weeks after discharge.
• Extra visits and telephone contacts were permissible if the nurse identified a specific need and purpose.

• General advice from ward-based staff, outpatient clinic follow-up as necessary and access to the local cardiac rehabilitation programme offered as per usual practice.

People (n=324) aged 65 years or over discharged home from hospital after emergency admission for suspected myocardial infarction.

Age: not stated

Percentage male: not stated

Ethnicity: not stated

UK

1. Intervention group (n = 48): Patients in the intervention group received home-based nursing intervention (HBNI) in addition to usual care from GP and OPD services. Home visits were made at 2-4 week intervals over 12 months

2. Control group (n = 48): Patients in the control group were not visited by a nurse but received care from GP and OPD services

Patients (n=96) with COPD who had to have a principal diagnosis of COPD, greater than 40 years of age, have a FEV1/FVC < 60%, have no other active major comorbidity, be in a stable state, have a carer involved in their management, and be able to speak and read English.

Australia

In Cochrane review: Home care by outreach nursing for COPD

The outcomes of the interventions were assessed at the end of the 12 month intervention

• Initial home visit by a specialist respiratory nurse – participants given a personalised COPD action plan (including advice on lifestyle, usual medication, antibiotics and steroids.
• Had monthly telephone calls from the respiratory nurses and a home visit every 3 months
• During each interview and visit, the nurses undertook a structured approach to history taking and during home visits measured pulse and respiratory rate, oxygen saturation and end-tidal carbon monoxide.
• Advice was reinforced regarding treatments, smoking cessation if relevant, the need to continue their exercise therapy and discussed and reinforced the self-management education which has been given and offered encouragement for successful self-treatment.

• Usual care from their primary care physician, or secondary care and/or the respiratory nursing service as appropriate.
• Use of healthcare monitored by monthly telephone self-report verified by confirmation of the general practice and hospital records.

People (n=122) with chronic obstructive pulmonary disease (COPD)

Age (mean range): 69.68-69.9 years

Percentage male: 49.2%

Ethnicity: not stated

UK

Participants in the intervention group received a hospital based-pulmonary rehabilitation programme for 4 weeks prior to nurse-led intervention.

Rehabilitation programme included general education about their disease at its treatment and underwent an individualised physical training programme.

• After discharge: Comprehensive assessment at home by a cardiac nurse 7-14 days after discharge.
• After home visit nurse sent report to primary care physician and cardiologist. Cardiac nurse arranged a flexible diuretic regimen for patient’s weight and symptoms if required.
• Phone call by cardiac nurse to patient contact at 3 and 6 months. Home visits repeated if a patient had 2 or more unplanned readmissions within 6 months of index admission
• Home visit included assessment of clinical status, physical activity, adherence to medication, understanding of disease, psychosocial support and use of community resources. Followed by (as appropriate): ’remedial counselling’ to patients and their families, strategies to improve adherence, simple exercise regimen, incremental monitoring by family/carers, urgent referral to 10 care physician.

• All study patients could be referred to cardiac rehab nurse, dietician, social worker, pharmacist and community nurse as appropriate.
• All patients had appointment with their primary care physician and/or cardiology outpatient service within 2 weeks of discharge.
• Regular outpatient review by the cardiologist was undertaken throughout the follow up period

Patients (n=200) admitted to tertiary care hospital under cardiologist and who had at least 1 previous admission for acute heart failure

Actual age of study subjects: control group mean 76.1 years (SD9.3), intervention group 75.2 years (SD 7.1) years

Male sex: 62%

Ethnicity: not given

Australia

In Cochrane review:

Clinical service organisation for heart failure

Duration of intervention: mainly within 2 weeks of discharge but some phone contact throughout study

Outcomes reported at 6 months follow-up

• Post discharge visits by the study nurse and pharmacist delivering remedial counselling, advice and information on medications, incremental monitoring by caregivers, referral to community pharmacist for more regular review thereafter. Study nurse evaluated clinical deterioration or adverse effects of medications and referred to GP where necessary.

• Usual post discharge care provided by GP or cardiologist (as outpatients). 27% of patients also received regular home support

Elderly patients (n=97) with chronic heart failure hospitalised for infarction or acute ischemia being discharged home but at high risk of unplanned readmission in

Australia

• 1st visit 2-3 weeks after discharge, nurses evaluated status, assessed treatment and provided education about HF and social support. Individualised education based on guidelines: information on HF, treatment, dietary advice, individually adjusted energy intake advice, lifestyle advice (including exercise), and promoted self-management
• nurses contactable by phone during office hours, Monday-Friday, and nurses called patients to provide psychosocial support and evaluate drug changes required
• extra appointments to attend HF clinic scheduled for patients unstable with symptoms of worsening heart failure
• patients referred back to primary health care once they were stable and well Informed

• Conventional follow-up in primary health care.
• Some patients got a scheduled visit after discharge, but most were encouraged to phone primary health care if they had problems due to heart failure

Patients (n=106) hospitalised for HF

Age: Control: 78 (SD 6), Intervention: 77 (SD 7)

Percentage male: Control: 32/54 (59%), Intervention: 33/52 (63%)

Ethnicity: Not stated

Sweden

In Cochrane review:

Clinical service organisation for heart failure

Outcomes reported at 12 months

Duration of intervention: not clear

• Appointment with specialist nurse prior to discharge, to receive info on HF and medications
• Office-hours contact number for nurse specialist
• Home visit with 10 days of hospital discharge, for education on symptom
• Management and lifestyle, and clinical examination
• Monthly nurse-led outpatient heart failure clinic for 6 months post-discharge, including education, clinical examination and indices monitoring, and starting of new therapeutic drugs where appropriate

• Standard care (that is, explanation of condition, prescribed medications by the ward nurse and referral to appropriate post-discharge support as required).
• Patients given an outpatient department appointment 6-8 weeks post discharge

Patients (n=106) with acute admission to hospital with a diagnosis of CHF.

Age: Control: 72 (SD 12), Intervention: 73 (SD 14)

Percentage male: Control: 73, Intervention: 72

Ethnicity: not stated

United Kingdom

In Cochrane review:

Clinical service organisation for heart failure

Duration of intervention: 6 months

6 month follow-up

• Home visit by nurses to provide symptom monitoring, education, and counselling and telephone follow-up by nurses in addition to routine follow-up by cardiologists
• A home visit was made within 14 days after discharge from hospital.
• Home visits were made once every 2 weeks until 2 months after discharge. After the 2 months, nurses then conducted monthly telephone follow-up until 6 months after discharge.
• Received comprehensive discharge education by cardiologist, nurse, dietician and pharmacist using a booklet that provided information on pathophysiology, medical treatment, diet, physical activity, lifestyle modification, self-measurement of body weight, self-monitoring of worsening HF, and emergency contact methods.

• Received comprehensive discharge education by cardiologist, nurse, dietician and pharmacist using a booklet that provided information on pathophysiology, medical treatment, diet, physical activity, lifestyle modification, self-measurement of body weight, self-monitoring of worsening HF, and emergency contact methods.

People (n=168) hospitalised for heart failure (HF)

Age (range): 75.8-76.9 years

Male percentage: 35%

Ethnicity: not stated

Japan

• Routine discharge care plus post-discharge home visit intervention. Protocol-driven.
• Community nurses made assessments, home visits based on Omaha system (health teaching, counselling, treatment and procedures, case management and surveillance.
• Case would be closed if health problems had resolved.

• Prerequisite and training of holistic case managers (community health nurses),
• Application of the Omaha system as nursing documentation
• Family meeting guided by motivational interviewing,
• Home visit, telephone follow-up and health and community care referral system

Not in Cochrane.

Thesis that includes this RCT

Perhaps better in rehabilitation part of the review?

• Home visits by a cardiac-trained nurse, a standardised nurses’ checklist, referral criteria for specialty care, communication with family physician, patient education

• Referral to non-invasive cardiac laboratory for diagnostic testing, followed up by cardiologist, received information on cardiac teaching class and rehabilitation. If referred to home care received the currently practiced home care (not specified what that entails)

Mortality (CRITICAL)

Avoidable adverse events (for example, sepsis) (CRITICAL)

Quality of life (CRITICAL)

Patient and carer satisfaction/carer burden (CRITICAL)

Presentation to ED (CRITICAL)

Length of stay (IMPORTANT)

Unplanned hospital admission (ambulatory care conditions) (IMPORTANT)

Delayed discharge (IMPORTANT)

Staff satisfaction (IMPORTANT)

The databases to be searched are:

Date limits for search: post 2005 – same search as intermediate care (relevance).

Language: English only, UK only – same as intermediate care (other healthcare systems very different).

Adults (17 years and above).

Young people (aged 16-17 years).

Interventions and comparators: generic/class; specific/drug

(All interventions will be compared with each other, unless otherwise stated)

Community matron or Nurse-led care.

Hospital-based care/services.

Usual Care.

-

Quality of life at during study period (Continuous) CRITICAL

-

Length of hospital stay at during study period (Continuous)

-

Mortality at during study period (Dichotomous) CRITICAL

-

Avoidable adverse events at during study period (Dichotomous) CRITICAL

-

Patient and/or carer satisfaction at during study period (Dichotomous) CRITICAL

-

Number of presentations to Emergency Department at during study period (Dichotomous)

-

Number of admissions to hospital at After 28 days of first admission (Dichotomous)

-

Number of GP presentations at during study period (Dichotomous)

-

Readmission up to 30 days (Dichotomous)

Early discharge.

Admission avoidance.

-

Frail elderly (frail elderly; not frail elderly); Different from younger population.

Databases: Medline, Embase, the Cochrane Library, CINAHL.

Date limits for search: No date limits.

Language: English only.

Patient outcomes;

Mortality (CRITICAL)

Avoidable adverse events (for example, sepsis) (CRITICAL)

Quality of life (CRITICAL)

Patient and carer satisfaction/carer burden (CRITICAL)

Presentation to ED (CRITICAL)

Length of stay (IMPORTANT)

Unplanned hospital admission (ambulatory care conditions) (IMPORTANT)

Delayed discharge (IMPORTANT)

Staff satisfaction (IMPORTANT)

Not looking at chronic disease-specific nurse practitioner (undifferentiated nurses; specialist nurses for example, COPD specialty nurses), community matron.

Non-UK studies – same as intermediate care (other healthcare systems very different).

The databases to be searched are: Medline, Embase, the Cochrane Library, CINAHL.

Date limits for search: post.

Language: English only.

Data synthesis of RCT data.

Meta-analysis where appropriate will be conducted.

Studies in the following subgroup populations will be included:

Frail elderly.

Rural versus urban.

In addition, if studies have pre-specified in their protocols that results for any of these subgroup populations will be analysed separately, then they will be included. The methodological quality of each study will be assessed using the Evibase checklist and GRADE.