ADVANCED PRACTICE

Transitional care in mechanical circulatory support: experience for advanced practice nursing

Ligia Neres Matos1,2, Liana Amorim Corrêa Trotte1, Julia Gonçalves Escossia Campos1, Lissette Aviles Reinoso1, Marluci Andrade Conceição Stipp1

1Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil

2Hospital Pró-Cardíaco, Rio de Janeiro, RJ, Brazil

ABSTRACT

Objective: To describe the nurses’ practice in the transition of care to adapt to the minimum home needs of patients with long-term mechanical circulatory support devices in a center in Rio de Janeiro. Method: The present study is an experience report on implementing home adaptations for transitional care of patients with long-term mechanical circulatory support devices, conducted at a center in Rio de Janeiro between January 2012 and July 2021. A checklist consisting of three domains was used to verify the necessary home adaptations, and the analysis was performed by descriptive statistics. Results: Low adequacy was observed in the domains related to communication, emergency plan, and fall risk. Conclusions: The use of the checklist by the coordinating nurse allowed an expansion of self-care education and improved the discharge planning process for these patients.

Descriptors: Transitional Care; Heart-Assist Devices; Home Calls; Heart Failure, Diastolic; Advanced Practice Nursing.

INTRODUCTION

According to the Global Burden of Heart Failure (2023), the prevalence of heart failure (HF) ranges from 1% to 3% of the adult population in developed countries(1). The prevalence is expected to increase substantially because of the increased availability of diagnostic therapies and medical treatment.

In Brazil, the annual incidence of HF is 240,000 new cases, with a prevalence of approximately 2 million patients(2). Noncommunicable chronic diseases are responsible for 72% of deaths in the country, with cardiovascular disease being the leading cause(3).

Epidemiological data show that between 2016 and 2020, the number of hospitalizations for HF in Brazil decreased, while an increase in mortality was observed in all regions of the country. This represents a significant public health problem and contributes to high mortality rates worldwide(4-5). Patients with advanced heart failure have severe signs and symptoms, even at rest, and experience recurrent hospitalizations despite management according to updated global guidelines. They are refractory or intolerant to treatment and require advanced therapies such as heart transplantation, mechanical circulatory support (MCS), and palliative care(6).

Nursing leadership in advanced HF has gained prominence in recent years, particularly in the United States, as new options for long-term MCS have become available. Of the various activities that have been developed, home adaptation counseling stands out as a practice that supports measures to maintain patient self-care(7).

The use of technology is becoming a fundamental part of care, especially for the terminally ill awaiting heart transplantation, making the use of MCS devices an effective strategy for hemodynamic control and, in many cases, the only chance of survival(8). Over the years, as new generations of devices have improved, the pace of their use has accelerated; as the number of patients with MCS increases and their survival improves, so do the demands on advanced practice nursing (APN) in this area of care(9). These devices have undergone progressive technological modifications by improving their operating mechanism, biocompatibility, and durability, allowing for patient discharge and indication-based care planning.

For patients to safely benefit from this therapy and improve their quality of life, nurses must have extensive knowledge, judgment, skills, responsibility, and independence. This may lead to the need for an additional scope of practice in the education of the generalist nurse, which is what distinguishes the APN. This additional breadth and depth of practice can be achieved through clinical practice experience, additional education, and at least a master’s or doctoral degree in the specialty(7).

Major national and international guidelines recommend discharge education to address these device use needs during the transition of care from hospital to home(8). A recent systematic review of the effectiveness of APNs for HF found that implementing this practice reduces hospital readmissions and mortality and has a better cost-effectiveness ratio than usual care(10).

Although the use of MCS has increased, it is used in a very characteristic group of patients; thus, there are some gaps in the literature regarding the support and adequacy of the home environment to receive them after hospital discharge(8).

Adapting to home environment requires the intervention of a specialized professional to ensure a safe, efficient transition. Although based on solid scientific evidence, this approach represents an innovative support that considers the clinical and demographic specificities of the patient. In addition, the specific needs of living outside the hospital environment must be met, including the organization of a home structure with access to coordinated health services(11-12).

When nurses can integrate technology in a thoughtful and balanced way, combining their experience in clinical and ethical judgment with the theoretical knowledge that underpins their work, it is evident that they are providing advanced care. Advanced practice nursing requires competence and evidence-based approaches to person-centered care(11-12).

Currently, the country has only four accredited centers for long-term MCS. The literature, especially in Brazil, needs more research that addresses the requirements related to preparing the home environment to better adapt to the patient's new reality. Therefore, this study aimed to describe the nurses’ practice in care transition and adaptation to the minimum home requirements of patients using long-term mechanical circulatory support devices in a center in Rio de Janeiro.

METHOD

This is an experience report of the nurse care coordinator’s practice at a long-term MCS center. Experience reports describe how situations, procedures, and daily planning are handled to help professionals reflect on and replicate them in other practice settings(13).

The study was conducted at an advanced heart failure center in Rio de Janeiro, a reference in high-complexity care and a pioneer in artificial heart implantation. It lasted from January 1, 2012, to July 31, 2021.

A total of 15 patients underwent MCS implantation at that center. The data collected included eight patients living in Rio de Janeiro who were discharged from the hospital and received a home visit from the specialist nurse. The procedure could not be performed in seven patients, of whom five died, one was transferred to another health care center, and one underwent heart transplantation.

A checklist consisting of three domains was used to collect data and verify the necessary adaptations in the home, considering the device manufacturer’s recommendations and guidelines for the care of patients with left ventricular assist devices (LVAD)(14-15). The first domain relates to the emergency plan, which includes communication between the patient and caregivers with the hospital reference team in emergencies. The second domain addresses device safety, which includes the electrical system and the placement of electrical outlets as a power source. The third domain focuses on fall prevention and provides specific guidance on placing furniture, carpeting, and bathroom fixtures.

The checklist was used in the patient’s home during a scheduled visit with a family member and/or caregiver, even during the hospitalization period, to check for adequacies and deficiencies and to provide suggestions for meeting the requirements prior to hospital discharge.

Data were collected and stored in an institutional database (Microsoft Office Excel 2016) and analyzed using simple descriptive statistics with the same software.

Ethical considerations

The study complied with the ethical aspects of Resolutions No. 466 of 2012 and No. 510 of 2016 of the Brazilian National Council for Research Ethics. The Research Ethics Committee approved this study under opinion No. 2,044,920.

RESULTS

Experience report

Eight home visits were made, representing 100% of the discharged patients. Approximately 37.5% of them lived in houses, and 62.5% in apartments. The mean age of the patients was 55, and the median age was 62.

Regarding the devices implanted, 62.5% were HeartMate II, and 37.5% were HeartWare. Overall, 50% of the patients were classified as Interagency Registry for Mechanically Assisted Circulatory Support I/II, and 62.5% used temporary MCS as a bridge to definitive therapy. The median life expectancy in this sample was 4.25 years, and 50% of the patients remained on therapy for more than 6 years.

The center’s nurse coordinator has more than 10 years of clinical experience with advanced HF patients, a master’s degree, and is currently pursuing a doctorate in the field. She also holds several international certifications required to work with patients on MCS. She is the first representative of the International Consortium of Circulatory Assist Clinicians in Latin America.

Regarding the emergency plan domain, patients were educated by the nurse during hospitalization to respond to emergencies (e.g., alarm triggers and power outages) (Table 1). In case of alarms, the patient needs to contact the hospital support team; therefore, we tried to facilitate the placement of telephones and the written record of hospital contacts to ensure they were easily visible. The presence of flashlights in the home was found to have the lowest percentage of adequacy (12.5%).

In an emergency, alarm detection and easy access to emergency telephones facilitate rapid intervention by the patient’s care team. In a power outage, the patient can be unplugged and connected to 14-volt batteries with flashlights for safe, quick action.

Before discharge, the implant center is advised to notify the utility company so that the patient is aware of planned disconnection activities. The patient is responsible for a detailed analysis of the quality of the electrical network and prior identification of circuit breakers and access to sockets in the home.

Table 1 – Descriptive analysis of the emergency plan domain verified during home visits to patients (n = 8) with long-term mechanical circulatory support devices. Rio de Janeiro, RJ, Brazil, 2022

LVAD components (e.g., battery charger, power module [HeartMate II and III], and power cord [HeartWare]) require electricity to operate. In device safety, the presence of appropriate outlets for proper use of the device and their location throughout the home were reviewed. Circuit breaker panels showed the highest percentage of inadequacy (100%), especially regarding instructions for restoring the power system. During the visit, the formal hiring of a professional (electrician) to check the sockets' polarity and assess the electrical system's condition was recommended (Table 2).

Table 2 – Descriptive analysis of the domain of equipment safety verified during home visits to patients (n = 8) with long-term mechanical circulatory support devices. Rio de Janeiro, RJ, Brazil, 2022

As per Table 3, low adequacy was found for lighting (50%), non-slip mats in the bathroom (37.5%), access to toiletries (25%), rugs that pose a fall hazard (25%), lack of non-slip backing on rugs (15.5%), lack of grab bars in the bathroom (12.5%), and changes in floor level between rooms (12.5%) — items related to the fall prevention domain.

Table 3 – Descriptive analysis of the fall prevention domain verified during home visits to patients (n = 8) with long-term mechanical circulatory support devices. Rio de Janeiro, RJ, Brazil, 2022

DISCUSSION

Patients who experience recurrent falls while using devices are associated with a higher incidence of serious adverse events and increased mortality. Therefore, more rigorous screening to identify fall risk factors before device implantation is critical(16). Changes in floor level, the presence of carpets, and the use of medications that affect sleep patterns, such as diuretics, may increase this risk.

In a study that used questionnaires to assess the human factors involved in the adaptation of 58 patients with LVAD, 65.3% of these patients modified their homes to adapt to life with LVAD. Although the study did not specify which household items were most frequently modified, it underscores the high demands placed on patients and their caregivers during the transition from the hospital to the home environment(17).

Coping with early and late-stage changes occurs between 3 and 6 months after device implantation. In the early stage, which occurs immediately after implantation, patients face challenges in adjusting to the home environment, dependence on therapy and caregivers, and limitations in socialization that need to be managed by the nurse. The late stage is characterized by functional improvement and quality of life, return to instrumental activities of daily living, and increased confidence from living with the device(18).

There is a clear consensus on the importance of post-discharge follow-up of these patients by a specialized interdisciplinary team, emphasizing the leadership of the device coordinator nurse in patient and caregiver education (14). Transitional care should begin in the preoperative phase and address the specific needs related to the patient's clinical aspects, who will depend on new technologies and devices for continuity of care. This includes guidance to promote patient autonomy in self-care and education for caregivers and family members, focusing on maintaining the patient's quality of life in the home environment.

Transitional care has been increasingly implemented to improve patient care post-hospital discharge. This includes discharge planning, coordination with local support teams, patient education, and post-discharge follow-up by the healthcare team(17,19).

Home modification counseling has been used as a fundamental strategy in the development of transitional care to get to know the home environment and promote education for the safe use of therapy while preventing damage to LVAD components. Current evidence supports the implementation of transitional care models to reduce hospital readmissions; however, further studies are needed to determine which components of these care models can provide the greatest benefit(20).

Living with a LVAD is a complex, stressful challenge for both patients and caregivers, who must adapt to a new routine and maintain regular follow-up by a specialized team(21). The introduction of new technologies often brings new demands that can increase the intensity of work, requiring not only the expertise of the specialist nurse but also an interdisciplinary approach involving professionals from different healthcare and related fields(22).

The official discussion of advanced nursing practice has gained prominence in the last decade, especially through debates in professional nursing councils. Although this practice is not yet a common reality in hospital units in the country, it is highly desirable, especially considering that hospitalized patients with decompensated HF require special care guided by clinical judgment and precise decision-making(23).

APN is emerging as an area of practice in which the nurse plays a central role in the provision and coordination of specialized care. Therefore, professionals must be prepared to apply new technologies and propose strategies to implement public policies that support the monitoring of users and their families and meet the needs of health professionals(7).

Strengthening the leadership of nurses, both current and future, is critical to ensuring that they can play an influential role in policy formulation and decision-making. This is essential to improving the effectiveness of health systems and promoting greater equity in access to health services, particularly in middle- and low-income countries(24).

Advanced practice registered nurses are recognized for their clinical leadership, which is demonstrated when they take independent control of treatment processes in complex care situations. They influence, develop, and implement change strategies, consult, educate, collaborate, and liaise with other healthcare professionals and management(25).

Therefore, professionals committed to providing holistic care that meets the individual's health needs and considers care perspectives at all levels of care are essential(7).

Furthermore, the importance of incorporating health advocacy as a competency for nurses to adopt in promoting the self-care of these patients must be emphasized. Specifically, understanding which models and approaches to health advocacy are essential and how to apply them in these specific contexts is critical(26).

CONCLUSION

The nurse care coordinator's use of the checklist allowed for the expansion of self-care education, improving the discharge planning process for this patient population.

The role of the APN in transitional care for this population is critical, especially in empowering patients for self-care, strategic planning, and continued implementation of home care. Using a personalized script that addresses these nursing practices' complex and unique needs can significantly improve the discharge planning process and ensure compliance with rigorous national and international guidelines.

The relational link between transitional care and patient outcomes assumes paramount importance when considering the diverse home environments and nurses' integral role in adapting approaches to support patients and caregivers in their daily activities. This link influences the quality of life, highlighting the critical contribution of nursing in transitional care and promoting patient well-being in diverse scenarios.

Furthermore, there is a need for more research that comprehends and conceptualizes a nursing theory in the care of HF in Brazil to guide nursing practice in this specific context.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

REFERENCES

1. Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: a comprehensive and updated review of epidemiology. Cardiovasc Res. 2023 Jan 18;118(17):3272-3287. https://doi.org/10.1093/cvr/cvac013

2. Cestari, VRF, Garces TS, Sousa GJB, Maranhão TA, Souza Neto JD, Pereira MLD, et al. Distribuição Espacial de Mortalidade por Insuficiência Cardíaca no Brasil, 1996-2017. Arq Bras Cardiol. 2022;118(1):41-51. https://doi.org/10.36660/abc.20201325

3. Oliveira JA, Pádua BLR, Cordeiro RG, Albuquerque DC. Domains analyzed in the assessment of resilience in individuals with chronic cardiovascular diseases: a scoping review. Online Braz J Nurs. 2022;21:e20226586. https://doi.org/10.17665/1676-4285.20226586

4. Ministério da Saúde (BR), Secretaria de Vigilância em Saúde, Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas e Agravos não Transmissíveis no Brasil 2021-2030 [Internet]. Brasília: Ministério da Saúde; 2021 [citado 2023 maio 31]. 118 p. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/svsa/doencas-cronicas-nao-transmissiveis-dcnt/09-plano-de-dant-2022_2030.pdf/view

5. Ministério da Saúde (BR), Departamento de Informática do Sistema Único de Saúde. DATASUS [Internet]. Brasília: Ministério da Saúde; [Citado 2021 Dez 08]. Disponível em: https://datasus.saude.gov.br/acesso-a-informacao/morbidade-hospitalar-do-sus-sih-sus/

6. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, et al. ESC Scientific Document Group. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-3726. https://doi.org/10.1093/eurheartj/ehab368

7. International Council of Nurses. Guidelines on Advanced Practice Nursing [Internet]. Geneva (CH): International Council of Nurses; 2020 [citado 2023 Aug 08]. Disponível em: https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf

8. Capriotti T, Micari M. Chronic Heart Failure Treatment With the Left Ventricular Assist Device. Home Healthc Now. 2019;37(4):190-197. https://doi.org/10.1097/NHH.0000000000000777

9. Starrh L, Becker D. Ventricular Assist Devices: The Basics. J Nurse Pract. 2018;14(7):538–544. https://doi.org/10.1016/j.nurpra.2018.05.001

10. Ordóñez-Piedra J, Ponce-Blandón JA, Robles-Romero JM, Gómez-Salgado J, Jiménez-Picón N, Romero-Martín M. Effectiveness of the Advanced Practice Nursing interventions in the patient with heart failure: A systematic review. Nurs Open. 2021;8(4):1879–1891. https://doi.org/10.1002/nop2.847

11. DeNisco SM. Advanced Practice Nursing: Essential Knowledge for the Profession. 4th ed.  Burlington (MA): Jones & Bartlett Learning; 2019.

12. Casida JM, Abshire M, Widmar B, Combs P, Freeman R, Baas L. Nurses' Competence Caring for Hospitalized Patients With Ventricular Assist Devices. Dimens Crit Care Nurs. 2019;38(1):38-49. https://doi:10.1097/DCC.0000000000000332

13. Casarin ST, Porto AR. Experience Report and Case Study: some considerations. J Nurs Health. 2021;11(2):e2111221998. https://doi.org/10.15210/jonah.v11i4.21998

14. Ayub-Ferreira SM. Resumo Executivo – Diretriz de Assistência Circulatória Mecânica da Sociedade Brasileira de Cardiologia. Arq Bras Cardiol. 2018;111(1):4-12. https://doi.org/10.5935/abc.20180126

15. Saeed D, Feldman D, Banayosy AE, Birks E, Blume E, Cowger J, et al. The 2023 International Society for Heart and Lung Transplantation Guidelines for Mechanical Circulatory Support: A 10- Year Update. J Heart Lung Transplant. 2023;42(7):e1-e222. https://doi.org/10.1016/j.healun.2022.12.004

16. Wong JK, Forrest A, Sherazi S, Massey HT, Prasad SM, Knight PA. Recurrent Falls in Patients with CF-LVAD’s Are Associated with Major Morbidity and Mortality. The Journal of Heart and Lung Transplantation. 2017;36(4):S100-S101. https://doi.org/10.1016/j.healun.2017.01.257

17. Schlöglhofer T, Grausenburger A, Widhalm G, Haberl L, Suda W, Schwingenschlögl H, et al. It's not only the pump: Assessment of human factors of wearable components and user experience of patients with left ventricular assist devices. J Heart Lung Transplant. 2023;42(4):466-477. https://doi.org/10.1016/j.healun.2022.12.015

18. Treb F, Spitz-Koeberich C, Rebafla A, Schibilsky D, Kaugler C. Balancing normalcy and safety: health-related needs in patients with a ventricular assist device within their home environment. Eur J Cardiovasc Nurs. 2022;21(5):446-452. https://doi.org/10.1093/eurjcn/zvab113

19. Bernardino E, Sousa SM de, Nascimento JD do, Lacerda MR, Torres DG, Gonçalves LS. Transitional care: analysis of the concept in hospital discharge management. Esc Anna Nery. 2022;26:e20200435. https://doi.org/10.1590/2177-9465-EAN-2020-0435

20. Iseler, JI, Wierenga, KL, Shaid, EC, & Hirschman, K. Implications of Transitional Care Interventions on Hospital Readmissions in Patients With Destination Therapy Left Ventricular Assist Devices. Research and Theory for Nursing Practice. 2019;33(1), 81–96. https://doi.org/10.1891/1541-6577.33.1.81

21. Abshire M, Russell SD, Davidson PM, Budhathoki C, Han H, Grady KL, Desai S, Himmelfarb CD. Social Support Moderates the Relationship betwen Perceived Stress and Quality of Life in Patients with a Left Ventricular Assist Device. J Cardiovasc Nurs. 2018;33(5): E1–E9. https://doi.org/10.1097/JCN.0000000000000487

22. Ozdemir Koken Z, Sezer RE, Kervan U. Caring for Patients With Ventricular Assist Devices: A Mini-Review of the Literature. Transplant Proc. 2019 Sep;51(7):2492-2494. https://doi.org/10.1016/j.transproceed.2019.03.046

23. Padua BLR de, Tinoco J de MVP, Dias BF, Carmo TG do, Flores PVP, Cavalcanti ACD. Cross-mapping of nursing diagnoses and interventions in decompensated heart failure. Rev Gaúcha Enferm. 2022;43:e20200400. https://doi.org/10.1590/1983-1447.2022.20200400.en

24. World Health Organization. State of the World’s Nursing 2020: Investigating In education, Jobs and Leadership [Internet] Geneva: WHO; 2020 [citado 2023 Aug 30]. Disponível em: https://iris.who.int/bitstream/handle/10665/332852/9789240007017-eng.pdf?sequence=1

25. Blanck-Köster K, Roes M, Gaidys U. Clinical-Leadership-Kompetenzen auf der Grundlage einer erweiterten und vertieften Pflegepraxis (Advanced Nursing Practice). Med Klin Intensivmed Notfmed. 2020;115(6):466-476. https://doi.org/10.1007/s00063-020-00716-w

26. Gandra EC, Silva KL. Advocacy for health promotion: meanings and approaches in the training of nurses. Reme: Rev Min Enferm [Internet]. 2019 [citado 2023 Aug 30];23:e-1247. Disponível em: http://www.revenf.bvs.br/scielo.php?script=sci_arttext&pid=S1415-27622019000100289&lng=pt&nrm=iso&tlng=en

Submission: 31-Aug-2023

Approved: 05-Feb-2024