IND Case study Person-centred, therapeutic education for patients with heart failure

Case Study Submitted by: Rita Akiki
Country: Lebanon

World Heart Day is celebrated on 29 September. This year, the campaign is asking the world to #Use Heart to help prevent cardiovascular disease and to celebrate the real-life heroes around the world committed to heart healthOn this day, ICN celebrates the work of #HeartHeroes, Rita Akiki and Marleine Saad and Rihane Zoghby, three nurses from Lebanon who are helping patients to regain their autonomy and become more involved in their own care.

Heart failure is a serious and costly chronic disease whose prevalence is constantly increasing, especially as the population ages. It is a public health issue. In Lebanon there is no national network for the management of heart failure, a disease which reduces the quality of life of patients. This important condition creates health, social and financial problems for patients. One in four patients are readmitted to hospital within 30 days of hospitalisation, and 50% die after five years.

In order to treat this serious health problem, the heart failure clinic was established at Aboujaoudé Hospital near Beirut.

The nurses’ input is vital because it enables patients to take back control of their lives, despite the debilitating condition they have to live with. Working closely with patients and their close family members, the nurses help the patients to understand their condition and find ways to work around the many problems it presents. They also act as vital links between the cardiologists and their patients, so that the treatment prescribed is accurately matched to the patients’ needs, and they are able to become autonomous again, and in many cases, continue to work.

The heart failure clinic has four aims:
(1) To provide the patient and his/her relatives with the best education on the different aspects of the disease, as well as on medicated and non-medicated treatment.
(2) To make the patient more autonomous and involved in his/her care to avoid burdens and relapses, as well as progression to more advanced stages.
(3) To accompany the patient and his/her family and friends throughout the illness, and prevent the need for rehospitalisation.
(4) To improve compliance with treatment and ensuring a better quality of life.

Officially opened in May 2019, the clinic provides therapeutic education and clinical follow-up. Patients are referred to the clinic by the cardiologist following hospitalisation, as well as after a consultation in a private clinic.

At the Heart Clinic, patients are managed by a multidisciplinary team that includes a nurse, a dietician, a physiotherapist, a social worker and a cardiologist. Nurses who are specialised in heart failure, engage in a holistic, therapeutic, education process with the patient and his/her family. Patients are accompanied by the same nurse to regain their autonomy, and make informed decisions. The nurse takes care of the patient and monitors the progress of his/her clinical condition through a series of successive appointments. The nurse works closely with the cardiologist to develop optimal treatment tailored to the individual needs of each patient. The nurse is always available to answer questions from patients who can reach her by phone during the clinic’s opening hours. The service is provided free of charge.

The nurses apply a personalised care plan that takes place in five steps during one-on-one interviews:
(1) Assess the patient’s educational needs to establish an educational diagnosis.
(2) Define the educational objectives with the patient.
(3) Each the patient and his/her family the adapted lifestyle based on learning tools.
(4) Perform a clinical nursing examination to detect signs of clinical aggravation and teach the patient how to detect warning signs based on a simplified tool (symptom checker).
(5) Maintain the skills acquired by nurses and update them in order to enable the patient to reach the best possible lifestyle.

The service includes education on:
• Multiple drug use and prevention of risks related to drug interactions.
• The importance of compliance with drug use.
• An assessment of precariousness and prevention of psychosocial disorders, especially social isolation syndrome and loss of autonomy.
• Motivation for the resumption of progressive physical activity.
• Introduction to a healthy lifestyle without tobacco and alcohol, and a healthy diet without salt and with a measured consumption of wate.
• Vaccination against diseases, especially influenza, pneumococcus, diphtheria, tetanus, and whooping cough.

The nurse contacts the cardiologist directly if necessary, to adapt the patient’s management programme, and a study of the impact of the patient’s therapeutic education on his/her quality of life is conducted once a year.

The clinic has seen 70 patients so far with the average age of patients being 74. Most patients are Lebanese and live with their families and half are women. The majority are workers who have not yet retired, even though they have passed normal retirement age of 65, a fact that reflects the Lebanese economic situation. These patients often live with health other problems, including as hypertension (60% of patients) and diabetes (30%).

The results of the study conducted in 2019 were shared with nursing colleagues at the 12th Annual Congress of the Lebanese Society of Critical Care Medicine. The results show that the programme increases patient satisfaction, leads to continuity of care and reduces stress and disability in patients with heart failure, who become autonomous and regain an independent lifestyle. In fact, 64% of the patients followed in the clinic were able to resume their activity and their social life. In addition, an increase in therapeutic and hygiene-dietary compliance is retained in patients, and nurses are more autonomous and more respected by families and physicians.

The project has shown that, with few resources, nurses can implement projects that make a big difference in people’s daily lives and reduce health care costs, as well as improving people’s quality of life. The key to the success of this innovative clinic is the involvement of nurses and their dedication to patients.

The nurses are collaborating, sharing their experiences, and open to mentoring motivated nursing colleagues to open similar clinics. In February 2020 the nurses conducted a workshop to share their expertise with colleagues from several hospitals. They we believe that sharing experience can motivate other nurse educators to implement similar heart failure education programmes.

In response to COVID-19 pandemic in Lebanon, the nurses organised a multidisciplinary webinar on heart failure that took place on July 2 and was delivered by the nurse educator and two cardiologists.
To maintain the well-being of the patients, telemedicine is being used to provide remote clinical services, especially virtual communication to interact with patients who are confined to their homes. A hotline is available for them to communicate with the nurse educator and awareness messages are sent to guide them on how to overcome the crisis.

The clinic’s latest project is a cross-specialty educational programme on the management of high-risk heart failure patients, encompassing cardiology, nephrology and diabetes. This programme will help the heart failure nurse educator and all the multidisciplinary team members to acquire the ability to diagnose, treat, and prevent heart failure in patients with chronic kidney disease and diabetes in a precise, clinically effective and cost-effective manner. The programme will be launched on September 29, the occasion World Heart Day.

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