Telehealth Nursing Practice

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PROTOCOL Effectiveness of advanced practice nurse-led telehealth on readmissions and health-related outcomes among patients with postacute myocardial infarction: ALTRA Study Protocol Karen Wei Ling Koh, Wenru Wang, A. Mark Richards, Mark Y. Chan & Karis Kin Fong Cheng Accepted for publication 17 December 2015 Correspondence to W. Wang: e-mail: Karen Wei Ling Koh MSN RN APN Assistant Director of Nursing/PhD Candidate National University Heart Centre Singapore, National University Health System and Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Wenru Wang PhD RN Assistant Professor Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore A. Mark Richards MD PhD FRACP Professor/Director Department of Medicine, University of Otago, Christchurch, New Zealand and Cardiovascular Research Institute, National University Health System, Singapore Mark Y. Chan MBBS MHS Associate Professor Yong Loo Lin School of Medicine, National University of Singapore, Singapore Karis Kin Fong Cheng PhD RN Professor Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore KOH K.W.L., WANG W., RICHARDS A.M., CHAN M.Y. & CHENG K.K.F. Effectiveness of advanced practice nurse-led telehealth on readmissions and health-related outcomes among patients with post-acute myocardial infarction: ALTRA study protocol. Journal of Advanced Nursing 72(6), 1357–1367. doi: 10.1111/jan.12933 (2016) Abstract Aim. To develop and examine the effectiveness of an advanced practice nurse-led telehealth rehabilitative programme as a transitional nursing therapeutic on readmission rates and health-related outcomes among patients with acute myocardial infarction postdischarge. Background. Patients suffering from acute myocardial infarction are experiencing an increasing trend of frequent readmissions. This implicates both the effectiveness of healthcare services and patient’s quality of life. Advanced Practice Nurse-led telehealth rehabilitative programme has yet to be explored as a strategy to minimize preventable readmissions and improve patient’s self-efficacy so as to enhance quality of life after a heart attack. Design. Randomized controlled trial with repeated measures. Methodology. A consecutive sampling of 172 patients with acute myocardial infarction will be recruited from a tertiary acute hospital in Singapore. Participants will be randomized into two groups. The experimental group (ALTRA) will receive Advanced Practice Nurse-led telehealth rehabilitative programme on discharge. The control group will receive only standard follow-up care. The outcome measures include readmissions, cardiac self-efficacy, cardiovascular risk factors, quality of life, anxiety and depression. The data will be collected at the baseline, 1 and 6 month postdischarge. A postprogramme evaluation will be conducted among the participants to assess its acceptability, strengths and weakness. Discussion. ALTRA aims to engage and support patients with acute myocardial infarction by increasing self-care management through education and telehealth contacts with Advanced Practices Nurses. This provides a smoother transition of illness to health and ultimately, reduces preventable costly readmissions. Trial registration. The study has been registered with The trial registration number is NCT02483494. Keywords: advanced practice nurse, cardiac rehabilitation, outcomes, postacute myocardial infarction, readmissions, telehealth © 2016 John Wiley & Sons Ltd health-related 1357 K.W.L. Koh et al. Why is this study needed?  Readmission after an acute myocardial infarction is a rising concern. The recovery and coping strategy after a traumatic life-threatening event can be very challenging for the patients.  Most patients do not attend the cardiac rehabilitation programme which aims to enhance quality of life and have shown to reduce readmissions. As such, newer nursing care strategies need to be developed and researched on to encourage self-care management while optimizing the right siting of care provision by the healthcare industry. Introduction Cardiovascular disease is the global leading cause of death with 73 million deaths attributed by coronary artery disease (CAD) in 2008 (World Health Organisation 2013). Ischaemic heart disease is the third leading cause of both death and illness for hospitalization in Singapore (Ministry of Health 2014a,b). Epidemiological data show that the incidence of acute myocardial infarction (AMI) in 2013 is 9463 in Singapore (Ministry of Health 2015). While advanced medical technologies have tremendously improved the in-hospital survival after an AMI, more patients are now at risk of readmission after being discharged into the community. In the USA, nearly 20% of patients with AMI are readmitted within 30 days of discharge costing its government a hefty USD 17 billion annually (Bradley et al. 2012, Centers for Medicare and Medicaid Services 2013). In National University Heart Centre, Singapore (NUHCS), approximately 108% of its patients (N = 743) with AMI were readmitted between August 2011–July 2012. Although NUHCS data maybe significantly lower, frequent readmissions inclusive of emergency department (ED) visits pose operational, resource and financial constraint on healthcare system. As of date, little is known in Singapore context as to an effective intervention to reduce such costly readmissions. The purpose of this paper was to present a research study protocol to examine the effectiveness of advanced practice nurse (APN)-led telehealth on readmission rates and health-related outcomes among patients with AMI. Current literature on interventions to reduce readmissions will be explored and the theoretical framework underpinning the research will be discussed. Background Readmissions have been shown to be associated with lower patient satisfaction and poorer healthcare quality and efficiency (Boulding et al. 2011). This certainly reflects the gap in the current clinical practice for postdischarge care of AMI 1358 patients. As such, the Centres for Medicare and Medicaid (CMS) in States have started to publish to publicly 30 days rehospitalization rates for heart failure, pneumonia and AMI in as part of a federal strategy in attempts to improve quality of care and reduce preventable readmission (CMS 2013). This stresses the urgency to ensure that health care is effective in meeting the needs of patients during the transition period from hospital to home and to keep them healthy in the community. The recovery and coping strategy after a traumatic lifechanging event can be daunting for both the patients and families. They often feel vulnerable especially when there is a lag time of a minimum one month’s wait in the follow-up appointment. During the stressful acute phase of hospitalization, educating self-care to patients pose to be challenging given that the lack of physical and psychological readiness due to their acuity of illness, fatigue and anxiety (Commodore-Mensah & Himmelfarb 2012). These do not only impacts the patient’s confidence level to perform certain lifestyle modifications for a healthy heart but also on psychosocial aspects of well-being as 15% to 20% of AMI patients subsequently develop anxiety or depression (Sarkar et al. 2007). It was also demonstrated in a prospective cohort study (N = 1024) that lower self-efficacy among CAD patients had statistically significant lower overall health and quality of life and higher physical limitation and symptoms burden (Sarkar et al. 2007). Such factors could have interplayed and resulted in patients seeking for medical attention via readmissions as a maladaptive coping strategy. Cardiac rehabilitation (CR), a structured programme comprises medical reviews, exercises, didactic education and personalized counselling, has been highly recommended as national guideline to provide effective secondary cardiovascular disease prevention to reduce risk factors profile, readmissions and enhancing the quality of life (Scottish Intercollegiate Guidelines Network 2002). In a meta-analysis (N = 63), secondary prevention programmes demonstrated a positive effect on risk factors, quality of life and even reduced recurrent AMI by 17% over a median of 12 months among CAD patients (Clark et al. 2005). The different strategies of: (1) education only; (2) education and supervised exercise; or (3) structured supervised exercise did not show superiority in terms of benefits (Clark et al. 2005). Despite its proven outcomes, participation rates of CR remain poor (Beswick et al. 2004). There is a multitude of factors that poses as a barrier for attending CR. For example, demographical factors such as age and transportation access, medical history such as severe myocardial infarction or multiple co-morbidities, or health belief such as nonattendee not wanting to be reminded of their heart conditions played a role in the low participation rates (O’Connell 2014). © 2016 John Wiley & Sons Ltd JAN: PROTOCOL It is imperative to seek for alternative strategies to engage and support patients during this transition of illness without the physical needs of travelling. A review of seven randomized controlled trials of patients with AMI demonstrated increasing evidence that home care with elements of education, exercise and nursing support postdischarge via home visits or telephone calls reduces readmission rates (Koh 2014). Reduction in readmissions will ultimately lead to decrease emotional and economic impact on the patient’s end. Studies, using the Master’s prepared APNs, have demonstrated reduced readmissions, lengthened time between readmissions and decreased healthcare cost. An example of beneficiary includes APNs rendering comprehensive discharge planning and home follow-up interventions in high risk of rehospitalizing older patients (Naylor et al. 2004, McCauley et al. 2006). Further rigorous research engaging APNs as part of the nursing therapeutics would serve to establish their effectiveness in optimizing healthcare services and reducing costly readmissions. In a systematic review (N = 9), telehealth was demonstrated to reduce both allcause and heart failure readmissions among chronic heart failure patients in two thirds of the trials (Chaudhry et al. 2007). Telemonitoring or telehealth is defined as the use of communication technologies to monitor patient’s clinical status remotely and is gaining attention as an intervention to facilitate and improve self-care of patients with chronic diseases (Chaudhry et al. 2007, Anker et al. 2011). A qualitative study showed that heart failure patients on telemonitoring for 6 months developed self-care skills in decision-making and ability to monitor their own conditions (Riley et al. 2013). The combination of increasing readmissions and low participation rates of secondary prevention programme like cardiac rehabilitation hold major implications for nursing practice in the delivery of care for post-AMI patients. Newer strategies need to be developed and researched on to cater to changing demands of healthcare consumers especially in encouraging self-care management while optimizing the right siting of care provision by the healthcare industry. The review on the seven randomized controlled trials showed limited but increasing evidence that home-based post-AMI programme implemented immediately postdischarge can assist the early recovery phase resulting in reduction in healthcare cost due to inappropriate use of health services such as hospitalization or ED visit (Koh 2014). With increasing complexities due to multiple co-morbidities and psychological issues in patients post-AMI, a home-based follow-up strategy using innovative remote monitoring via telehealth and APNs to provide patient’s rehabilitative care is a potential area of research to evaluate its effectiveness to reduce readmissions and improve health-related outcomes. © 2016 John Wiley & Sons Ltd ALTRA study Theoretical framework Meleis’ middle-range theory of transitions has been selected as a guiding framework for conceptualizing the transitional nursing care therapeutics and its relevant study variables in relations to transiting from hospital to home after a lifechanging event such as AMI (Meleis et al. 2000). This change in health status places an individual into a transition process and a period of vulnerability to risks that may in turn affect their health (Meleis et al. 2000). The development of nursing therapeutics should be focused on preventing unhealthy transitions while health and well-being is the outcome of the process (Meleis & Trangenstein 1994). The four main components of the transition theory that will be explored in this study include: (1) nature of the transition – AMI as health and illness event requiring hospitalization; (2) transition conditions – patient’s demographics; (3) nursing therapeutics – APN-led telehealth with care mon- itoring and education; and (4) patterns of response – readmissions, confidence level, sub- jective and objective well-being. Figure 1 illustrates the proposed theoretical framework with its variable for this study. The theory proposes that the first three dimensions will affect the individual’s patterns of response during the transition. The three time frames of transition flow in this study are: (1) hospitalization during which discharge preparation occurs; (2) transitional phase postdischarge supported with nursing interventions and (3) home at community. The study Aims The aim of the study is to develop and examine the effectiveness of an APN-led telehealth rehabilitative programme as a transitional nursing therapeutic on readmissions and health-related outcomes among patients with AMI postdischarge. Research questions The research questions are as follows: (1) What is the effectiveness of APN-led telehealth programme (ALTRA) in: • • reducing readmission days per 1000 follow up days, improving health-related outcomes including cardiac self-efficacy, cardiovascular risk factors, quality of life, anxiety and depression? 1359 K.W.L. Koh et al. Unhealthy Hospital Home @ Community Transition Support Healthy Patterns of Response Nature of Transition Health/Illness Related Process Indicators Developing Confidence and Coping with New Lifestyle - Acute Myocardial Infarction & Status - Admission Status - Length of Stay Transition Conditions Patient Characteristics - Nursing Therapeutics APN-led Telehealth - Care monitoring - Education Age/Gender/Race Socioeconomic Status Lives Alone Risk Factors - Cardiac Self Efficacy - CV Risk Factors - Quality of Life - Anxiety/Depression Outcome Indicators Mastery for Healthy Transition - Readmission - Emergency Visit Figure 1 Theoretical framework. (2) What are the participant’s perceptions and experiences using ALTRA? either to the experimental or control group using pre-sealed envelopes. Research hypotheses Participants It is hypothesized that compared with those in the control group, participants in the ALTRA group will: (1) have significantly lower readmission days per 1000 follow up days; (2) have significantly higher levels of cardiac self-efficacy; (3) have significantly better control of cardiovascular risk factors; (4) report significantly higher levels of quality of life; (5) report significantly lower levels of anxiety and depression. Sampling method The target population will be high-risk patients admitted to a tertiary acute hospital in Singapore with an episode of AMI. A consecutive sampling of patients admitted to Coronary Care Unit (CCU) or cardiac wards of the acute hospital will be adopted over an 18 months interval. Inclusion criteria are: (1) age above 21 and below 85; (2) clinical diagnosed and documented AMI as primary diagnosis managed by NUHCS including pre-discharge N-Terminal –pro Brain Natriuretic Peptide (NT-proBNP) ≥400 pg/mL for STEMI and ≥600 pg/mL for NSTEMI; (3) Undergone PCI for the index event; (4) able to read and speak English and Chinese; and (5) has access to telecommunications. Exclusion criteria are: (1) patients discharge to institutionalized care; (2) coexisting terminal illness such as cancer; (3) psychiatric or cognitive disorders; (4) impaired bilateral hearing or vision and (5) patients requiring vascularization via coronary artery bypass graft surgery. The use of NT-proBNP as a prognostic predictor of cardiovascular death and stroke was clearly demonstrated in a Design/methodology Design The research is designed as a single-centre randomized twoarmed parallel controlled trial to examine the effectiveness of APN-led telehealth in reducing readmission days in high risk AMI patients. After obtaining written consent and baseline measurements, the study participants identified as high-risk will be stratified and then randomly assigned 1360 © 2016 John Wiley & Sons Ltd JAN: PROTOCOL longitudinal study (N = 3761) and this would help clinicians to better identify patients who were of a higher risk resulting in a need for hospitalization (Omland et al. 2007). Based on cardiologists’ expert opinions on analysis of local data, the cut-offs for the NT-proBNP levels have been recommended for Asian population to be of a higher risk of all subsequent post-AMI deaths and heart failure events. Sample size determination A conventional medium effect size, according to Cohen’s recommendation and a previous study with 50 per cent reduction in readmission days per 1000 follow up days, will be used to determine the sample size required (Cohen 1992, Young et al. 2003). A minimum sample size of 63 in each arm and a total of 126 would be required to detect a minimally important difference in reducing relative readmission days of 50 per cent between the two groups at 80% power and 5% error. An attrition rate of 35% is estimated for this study based on a previous study that examined the effect of telephonic follow-up of AMI patients postdischarge on health-related quality of life (Hanssen et al. 2009). It is planned to recruit a minimum of 172 participants in this study with 86 patients in each group. Randomization Patients who are admitted to CCU or cardiac wards will be screened for eligibility. Once eligible, patients will be invited to participate in the trial and an informed consent will be taken by the principal investigator. Thereafter, a blood sample will be taken to measure the NTproBNP level. After meeting the required levels of NTproBNP, participants will first undergo stratified randomization according to the Acute Coronary Syndrome subgroup: ST-Elevation Myocardial Infarction (STEMI) and Non ST-Elevation Myocardial Infarction (NSTEMI). Thereafter, they will be randomized into the TELEHEALTH vs. CONTROL group in 1:1 sequential block randomization (blocks of 4-6). This is to achieve treatment groups of equal sizes (Schulz & Grimes 2002). Randomization will be done manually with sequentially numbered, opaque pre-sealed envelopes at the research site. The envelope will be drawn for each successfully recruited participant without replacement. A new bag of envelopes will be created for subsequent varying blocks until the sample size has been achieved. Study intervention APN-Led teleheath rehabilitative programme The experimental arm will receive APN-led telehealth management for: (1) 2 months of intensive telehealth follow-up; and (2) continuous monitoring with calls for the subsequent © 2016 John Wiley & Sons Ltd ALTRA study 4 months. Both groups will receive usual follow-up care which comprises inpatient education by cardiac care nurses, cardiologist, or APN follow up at first and fifth month postdischarge and option to enrol into outpatient structured cardiac rehabilitation programme. Initial ...
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School: Rice University

Hi, Find attached the paper for your review.Let me know if you need anything edited or changed.Looking forward to working with you again in future.Thank you


Telehealth Nursing Practice



Telehealth Nursing Practice
The article by Koh et al. (2016) presents fundamental aspects that relate to nursing care,
general health, patient safety, research, nursing practice, theory and so on. The primary objective
of the article is to examine and develop the efficiency of progressive nursing-led tele-health
rehabilitative program. The study also aims at determining how this program transitions nursing
therapeutic on the rates of readmission as well as health-linked outcomes among patients
suffering from myocardial infarction post discharge. With the adoption of a design that uses
randomized controlled trial that had repeated measures, the study explores the program as a
strategy particularly to decrease preventable readmissions and at the same time develop the self efficiency of the patients to improve a patient’s quality of li...

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