The purpose of the study is to analyze and describe the telephone contacts between nurses and patients with chronic heart failure living at home. Frequent contact to monitor and support people at home with heart failure is essential for early intervention, prevention of catastrophic admissions and to reinforce self-monitoring. Telephone monitoring by specialized nurse-clinicians is a key component of a nurse-managed multidisciplinary outpatient heart failure program at a large Southwestern hospital. Each person enrolled in the program also receives two education sessions and regular clinical assessment and intervention. OBJECTIVES: a) To analyze the time, reported symptoms and related nursing actions of phone contacts. b) To evaluate patient satisfaction with this monitoring protocol. c) To evaluate use of the “Heart Health Diary” as a self-monitoring and communication tool. SAMPLE: During a four-year period, 300 patients who were enrolled in the telephone-monitoring program generated a total of 4,016 telephone calls with the nursing staff. Of those 300 patients, 41 reported 5 or more symptoms, subsequent 102 calls were analyzed. METHODS: This study is a preliminary retrospective descriptive analysis of the102 telephone contacts with the 41 NYHA Class III and IV patients. Outpatient Heart Failure Center nurses call the patients regularly with frequency based on NYHA class and individual patient assessment. The telephone protocol consists of 20 questions related to heart failure symptoms, adherence to diet and medications and contact with health providers. Patients are instructed to call the nurses if they experience weight changes or new symptoms. All calls with patients are logged in a computer database called CHF Manager. FINDINGS: The calls were with 33 men and 8 women with an average age of 63.7 (29-89 years). The mean New York Heart Association (NYHA) functional class was 3.1 (1-4). The average length of call was 10 minutes (1-50 minutes) with an average 2.5 contacts per patient. 96.2% weighed themselves daily. The most frequently reported symptoms in both data sets (4016 calls and the 102 calls) in order were: a) increased fatigue, b) dyspnea on exertion, c) swelling d) increased weight. Of the 102 calls, the nursing actions in order of frequency were: a) telemonitor (no immediate intervention required), b) notify a cardiologist, c) schedule a clinic appointment, d) adjust medication(s) per protocol and provide emotional support. The telephone protocol was ranked high for patient satisfaction with 60% stating "extremely helpful" on a 5-point Likert scale. The "Heart Health Diary" for self-monitoring was used by 51% of the sample. Nurses initiated 49% of the calls while patients initiated 42% of the calls. CONCLUSIONS: Telephone monitoring is an important component of outpatient heart failure care for assisting patients with symptom management and reinforcing education. The frequently reported symptoms suggest essential questions to ask patients during phone contacts. The five core nursing actions suggest a model of practice for outpatient nursing care with this or other chronic illness populations, requiring further study. High patient satisfaction supports this telephone-monitoring program as an accepted method for communication with patients. IMPLICATIONS: This study is the initial phase. We plan further analyses of the larger data set of 4,016 calls with the following questions: 1. Do those who use the Heart Health Diary report symptoms earlier and have better outcomes? What are the characteristics of people who use the diary compared with those who don't? What changes, if any should be made to the Diary? 2. Are symptoms requiring intervention more commonly identified during nurse or patient-initiated calls? Are nurse-initiated calls the most cost-effective? 3. Specialized nurse-clinicians regularly assess the stability and functional status of each patient via the telephone. The nurses determine the level of intervention required and the relative urgency. For each nursing action, what cluster of symptoms triggers the action? Describing the process of critical thinking during telephone intervention may illuminate the nursing competencies required in an outpatient setting.
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