BackgroundHospital admissions for heart failure are predicted to rise substantially over the next decade placing increasing pressure on the health care system. There is an urgent need to redesign systems of care for heart failure to improve evidence-based practice and create seamless transitions through the continuum of care. The aim of the review was to examine systems of care for heart failure that reduce hospital readmissions and/or mortality.MethodElectronic databases searched were: Ovid MEDLINE, EMBASE, CINAHL, grey literature, reviewed bibliographies and Cochrane Central Register of Controlled Trials for randomised controlled trials, non-randomised trials and cohort studies from 1st January 2008 to 4th August 2015. Inclusion criteria for studies were: English language, randomised controlled trials, non-randomised trials and cohort studies of systems of care for patients diagnosed with heart failure and aimed at reducing hospital readmissions and/or mortality.Three reviewer authors independently assessed articles for eligibility based on title and abstract and then full-text. Quality of evidence was assessed using Newcastle-Ottawa Scale for non-randomised trials and GRADE rating tool for randomised controlled trials.ResultsWe included 29 articles reporting on systems of care in the workforce, primary care, in-hospital, transitional care, outpatients and telemonitoring. Several studies found that access to a specialist heart failure team/service reduced hospital readmissions and mortality. In primary care, a collaborative model of care where the primary physician shared the care with a cardiologist, improved patient outcomes compared to a primary physician only. During hospitalisation, quality improvement programs improved the quality of inpatient care resulting in reduced hospital readmissions and mortality. In the transitional care phase, heart failure programs, nurse-led clinics, and early outpatient follow-up reduced hospital readmissions. There was a lack of evidence as to the efficacy of telemonitoring with many studies finding conflicting evidence.ConclusionRedesigning systems of care aimed at improving the translation of evidence into clinical practice and transitional care can potentially improve patient outcomes in a cohort of patients known for high readmission rates and mortality.

Background Many dedicated Coronary Care Units (CCUs) in Victoria, Australia, have been decommissioned and replaced with larger combined generic medical/cardiac precincts called hybrid units. Hybrid units are staffed with a low proportion of specialist critical care nurses. These changes may pose risks to nurse satisfaction and retention, and quality of patient care. The aims of this study were to explore specialist cardiac nurses’ perceived work satisfaction across four CCUs, and differences in satisfaction between dedicated and hybrid CCUs. Methods This concurrent mixed methods study comprised two Phases in four Victorian CCUs (2 dedicated, 2 hybrid). In Phase 1, 74 specialist cardiac nurses completed the Professional Practice Environment (PPE) Scale. In Phase 2, 17 specialist cardiac nurses were interviewed to further explore elements of the PPE subscales. Descriptive, inferential (Phase 1), and content analyses (Phase 2) were performed. Results Survey participants’ median age was 38 years (IQR 30, 45). The median PPE Scale score was 3.10 (IQR 2.90, 3.10) indicating high levels of satisfaction with their workplaces. Specialist cardiac nurses in one hybrid unit were significantly less satisfied compared with each of the other three units ( p < 0.05). There were no significant differences in overall satisfaction or in any subscale of the PPE Scale between dedicated and hybrid units. Qualitative data revealed nurses in hybrid units felt they had less control over practice, lacked autonomy, had poor relationships with physicians, and experienced inadequate nurse leadership. Conclusions Specialist cardiac nurses’ workplace satisfaction overall is high, with no significant differences between dedicated and hybrid CCUs. However, the structure of specialist cardiac units and NUM leadership skill level can impact nurses’ satisfaction with their workplace and collegial relationships. Strong nursing leadership that is respectful of nursing expertise and places patient safety foremost positively impacts nurses’ satisfaction. Further studies should assess the impact of the types of CCUs and NUM leadership on workforce factors such as nurse retention rates and patient outcomes such as adverse events.

Background: It remains unclear whether obesity, measured by body mass index (BMI) is an independent risk factor of morbidity and mortality after coronary artery bypass grafting (CABG). We sought to determine whether body fat distribution, measured by waist circumference (WC), hip circumference (HC) and waist-to-hip ratio (WHR) is a better predictor of postoperative complications after CABG than BMI. Methods: 2,062 patients who underwent isolated elective on-pump CABG with documented BMI were identified from the ANZSCTS database (2010-2019) at St Vincent's Hospital, Melbourne. Our primary analysis assessed the relationship between BMI and postoperative complications using multivariable logistic regression. Secondary analysis included only those patients with recorded waist and hip circumferences (n=640). WHR, WC and HC were compared with incidence of postoperative complications in multivariate analyses. Results: BMI was associated with an increased risk of new renal failure (OR 1.08, p,0.00). Increasing WHR significantly increased the risk of prolonged intubation in females (OR 1.12, p,0.01). In males, both WC and HC were significantly associated with increased risks of new renal failure (OR 1.06, p,0.00; OR 1.07, p,0.00) and ICU readmission (OR 1.05, p,0.01; OR 1.04, p,0.04). Conclusion: WC, HC and WHR may be useful screening tools in identifying patients at risk of postoperative complications. This study is one of the first to consider these alternative anthropometric measures to BMI in predicting postoperative outcomes following CABG.

Aims Heart failure nurse practitioners (HF NP) are an emerging component of the heart failure (HF) specialist workforce but their impact in an inpatient setting is untested. The aim of this paper is to explore the impact of an inpatient HF NP service on 12 month all-cause rehospitalisations, emergency department (ED) presentations and mortality in patients hospitalised with HF compared to usual hospital care. Methods and results Retrospective, 2-group comparative design involving patients (n = 408) admitted via ED with acute HF to a metropolitan quaternary hospital between January 2013 and August 2017. Doubly robust estimation with augmented inverse probability weighting (DR-AIPW) was used to account for the non-random allocation of patients to usual hospital care or the HF NP service in addition to usual in-hospital care. Among 408 patients (186 usual care; 222 HF NP service) admitted with acute HF, mean age was 76.5 (SD 12.0) years and 56.4% (n = 230) were male. After IPW adjustment, patients seen by the HF NP service had lower risk of 12-month rehospitalisation (61.3% vs 78.3% usual care; difference —16.9%, 95%CI: -26.4%, -6.6%) and ED presentations (12.6% vs 22.0%; difference —9.4%, 95%CI: —17.3%, —1.4%) with no difference in 6- or 12-month mortality. The HF NP service improved referrals to a home visiting program that was available to HF patients (64.4% vs 45.4%; difference 19%, 95%CI: 8.8%, 28.8%). Conclusion Additional support by an inpatient HF NP service has the potential to significantly reduce rehospitalisations and ED presentations over 12 months. Further evidence from a multicentre RCT is warranted.

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