Running head: CONGESTIVE HEART FAILURE 1

Congestive Heart Failure

Student’s Name:

Institutional Affiliation:

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Congestive Heart Failure

Introduction

As a medical surgical nurse, we focus on making sure that we document thoroughly on

heart failure patients. The documentation focuses on core measures developed by CMS.

Inadequate patient education, compliance of medications, lack of willinglessness to change life-

style, and several other causes are some of the main reasons that lead heart failure patients back

into the hospitals. The frequent hospitalization impact quality measures of facilities which then

decrease reimbursements overall. Aging baby boom generation will produce a sharp increase in

the number of people who will die from heart disease. It is projected that by 2020, heart disease

will be the leading cause of death and disability (Levenson et al., 2009). Although the symptoms

of HF can be treated and improved by medication therapy, underlying cause also needs to be

treated to prevent progression and worsening of symptoms. Some drugs improve symptoms

(Diuretics, Digoxin, and Ace Inhibitors) while others offer symptomatic and prognostics benefits

(Ace Inhibitors, Beta Blockers, Oral Nitrates plus Hydralazine, and Spironolactone) aimed at

both improving quality of life and survival. In this final proposal, the IOWA model will be

utilized in addressing the clinical issue identified as well as the PICOT question.

The design of the model helps guide clinical practice through a scientific method of

evidence based research with an ultimate goal of providing answers to the clinical question as

well as the prediction of patient outcomes. The model will enable focusing on knowledge as well

as triggers that are focused on the problem and will also make it possible to question the current

practices and whether improvements can be made with the research findings. The various steps

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of the model include topic selection, team formation, and retrieval of evidence, evidence grading,

EBP standard development, EBP implementation and evaluation.

Magnitude of Problem

Congestive heart failure (CHF) refers to a condition that is progressive affecting the heart

muscles pumping power. It is also called heart failure and CHF is a specific stage where there is

a buildup of fluids around the heart which cause inefficient pumping. The most common type is

left sided CHF where the left ventricle fails to pump blood out properly. The condition affects

over 6.5 million people in the United States and has been found to have 50% mortality rates

within five years of diagnosis (Komanduri et al., 2017). Recommendations and clinical

guidelines prescribe the use of beta blockers, ACE inhibitors, as well as statins after a heart

attack with the effectiveness of such therapies being dependent on adherence.

Trigger Identification

Triggers can be identified from questioning of current practice. Studies report that close

to 40% of patients that have initiated HF therapies become non-adherent in the first year of

treatment. This is associated with challenges of adhering to the multiple therapies, interactions

between drugs and ADE’s which cause patients to adhere to only some of the therapies (Riegel

& Dickson, 2016). Most CHF patients have complex treatment regimens and clinicians need to

balance the risks and benefits of the recommended therapies with most of the evidence focusing

on the efficacies of single therapies rather than a combination. Hospitals have recently been

affected by financial penalties that are a result of HF readmissions and many of these

readmissions can be associated with lack of adherence to medications or the medications proving

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to be ineffective in improving outcomes. Tradeoffs therefore need to be made among the

therapies after congestive heart failure.

Organizational Priority

After identifying the trigger, the Iowa model recommends the determination of whether it

is considered a priority in the organization as well as in the perception of the staff (Doody &

Doody, 2011). The researcher will have to consider where it fits with regard to the specific

priorities of the organization, unit or department. This will be important in order to acquire the

resources and support necessary for ensuring the practice changes are sustainable. To determine

the fit between the topic and priorities of the organization, indicators that will be evaluated

include trends, improvement plans and strategic plans. The relevant CHF studies advocating for

change will also be discussed with those in leadership roles.

Team Formation

Processes of altering the delivery of care and care practices needs the input, expertise as

well as support of all who are involved in the EBP change. The team should incorporate key

interdisciplinary stakeholders who are representative of all disciplines involved. Their efforts

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will be essential in the development, implementation and evaluation of the change in practice

(Doody & Doody, 2011). Those selected will have to be familiar with and interested in the topic

selected for change in practice. The team that will be selected for evaluating effectiveness of

different CHF therapies will include frontline staff like nurses and physicians as well as

caretakers of those who have experienced CHF. The approach of utilizing front line staff instead

of management in a bottom up approach has been found to be more effective in making EBP

changes. Communication and collaboration within the team will focus on change

implementation, what is needed to improve outcomes, making of decisions as well as the needed

collaborations for change sustenance.

Evidence Retrieval

The purpose of this study is to answer the compelling question as to what CHF therapies

are more effective in improving outcomes after congestive heart failure. With an aim of building

on the existing research and answering the research question, the following PICOT question was

formulated;In heart failure patients (p), how does beta-blockers (i) compared to ACE inhibitors

(c) affect the treatment (o) of newly diagnosed heart failure patients within one year (t)?In order

to address this question, different data sources were used and this involved the search of

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literature in search engines and electronic databases like Medline, CINAHL, Cochrane, Pubmed

as well as Google Scholar. Published literature and journals were searched in the search engines

and databases where only the original articles published from the year 2014 and written in

English were retrieved. Keywords such as congestive heart failure, ACE, beta blockers,

inhibitors, heart failure, new diagnosis and treatment were utilized.

Evidence Grading

For evidence grading, areas of quality of the individual studies as well as evidence

strength of the research was addressed. Quantitative literature was utilized which are usually

based on deduction processes, testing of hypothesis and methods which ensure phenomena is

controlled with a focus on prediction and testing of theory. Factors that were in consideration

included the scientific merits, types of enrolled subjects as well as the clinical relevance.

Quantitative methods are considered to give an objective and unbiased picture of the phenomena

or situation.

Developing Evidence Based Standard

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After the literature has been critiqued, recommendations for practice need to be set. There

needs to be clarity on the strength as well as type of evidence utilized in practice. Determinations

also need to be made as to whether the data is sufficient for guiding the change in practice.

Criteria utilized in such a decision include findings consistency, quality and type of study,

relevance to the topic, and the ratio of benefits to risks. From the literature review, various

discoveries were made which included: 1. beta blockers alone had limited benefits in patients

compared to ACE inhibitors and statins (Korhonen et al., 2017). 2. Patients with severe or

moderate functional or cognitive impairment were likely to become functionally declined due to

the use of beta blockers (Steinman et al., 2017). 3. Treatment with optimal beta blocker doses

alone enabled significant reductions in risks of death as well as the number of hospitalizations

(Taneva & Caparosca, 2016). 4. There is a consistent treatment benefit with the combined use of

ACE inhibitors like perindopril regimen with beta blockers (Brugts et al., 2017). 5. LCZ696 is

superior to other therapies like enalapril in the reduction of risks of death and hospitalization that

are a result of heart failure (McMurray et al., 2014).

Implementing EBP

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The Iowa model recommends that the next step should be piloting of the practice change

before a full implementation is conducted in practice. This allows the change to be applied in

everyday practice and determine the extraneous variables that can influence the results. With

heart failure, there can be many variables that can influence outcomes including medication

regimens that are complicated as well as self-care challenges and support after discharge.

Piloting of the recommended change therefore allows identification of these variables and this

involves selection of achievable outcomes, collection of baseline data, guidelines development,

and evaluation of trial outcomes. A two week trial period can be conducted before the full EBP

change is implemented after which the findings can be discussed in the team.

Evaluation

This involves determining the contribution and value of the change in practice. Baseline

data collected before implementation above would be helpful as it would show how the evidence

has made contributions in care. Barriers that can be obstacle to the change progress need to be

identified and this can include skill deficit and lack of information which are common in

evidence based practice changes. A force field analysis can be utilized in identifying barriers as

well as an impact evaluation for the determination of the changes immediate effect to practice.

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Application for Funding

Before applying for funding, it would be essential to study the funding sources to

determine if it is the appropriate funding body for the proposed project and if their priorities

match those of the research to be conducted. Various bodies also have different criteria for

applying for research funding with many utilizing an online platform. Guidelines for submission

need to be read carefully with a strict adherence to what has been stipulated. Clarity will also be

required in articulating how the project will bring change, improve practice or lead to

advancements in research. Details of a strong team for research delivery also need to be

stipulated as well as what their contributions will be. Careful budgeting also needs to be

conducted with regard to all aspects of the project.

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References

Brugts, J. J., Bertrand, M., Remme, W., Ferrari, R., Fox, K., MacMahon, S., ...&Boersma, E.

(2017). The treatment effect of an ACE-inhibitor based regimen with perindopril in

relation to beta-blocker use in 29,463 patients with vascular disease: a combined analysis

of individual data of ADVANCE, EUROPA and PROGRESS trials. Cardiovascular

drugs and therapy, 31(4), 391-400.

Doody, C. M., & Doody, O. (2011). Introducing evidence into nursing practice: Using the IOWA

model. British Journal of Nursing, 20(11), 661-664.

Hamood, H., Hamood, R., Green, M. S., &Almog, R. (2015).Effect of adherence to evidence‐

based therapy after acute myocardial infarction on all‐cause

mortality. Pharmacoepidemiology and drug safety, 24(10), 1093-1104.

Komanduri, S., Jadhao, Y., Guduru, S. S., Cheriyath, P., & Wert, Y. (2017). Prevalence and risk

factors of heart failure in the USA: NHANES 2013–2014 epidemiological follow-up

study. Journal of community hospital internal medicine perspectives, 7(1), 15-20.

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Korhonen, M. J., Robinson, J. G., Annis, I. E., Hickson, R. P., Bell, J. S., Hartikainen, J., &

Fang, G. (2017). Adherence tradeoff to multiple preventive therapies and all-cause

mortality after acute myocardial infarction. Journal of the American College of

Cardiology, 70(13), 1543-1554.

McMurray, J. J., Packer, M., Desai, A. S., Gong, J., Lefkowitz, M. P., Rizkala, A. R., ...&Zile,

M. R. (2014). Angiotensin–neprilysin inhibition versus enalapril in heart failure. New

England Journal of Medicine, 371(11), 993-1004.

Riegel, B., & Dickson, V. V. (2016).A qualitative secondary data analysis of intentional and

unintentional medication nonadherence in adults with chronic heart failure. Heart &

Lung: The Journal of Acute and Critical Care, 45(6), 468-474.

Steinman, M. A., Zullo, A. R., Lee, Y., Daiello, L. A., Boscardin, W. J., Dore, D. D., ... &Mor,

V. (2017). Association of β-blockers with functional outcomes, death, and

rehospitalization in older nursing home residents after acute myocardial infarction. JAMA

internal medicine, 177(2), 254-262.

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Taneva, B., & Caparoska, D. (2016).The impact of treatment with beta-blockers upon mortality

in chronic heart failure patients. Open access Macedonian journal of medical

sciences, 4(1), 94.