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Congestive Heart Failure

Rogert Castro Alfaro

South University Online

Abstract

This paper explores five published articles on congestive heart failure that focuses on readmission rates and the development of effective discharge plans to reduce rehospitalization. Congestive heart failure has been the major cause for readmissions globally and thus impacted on the quality of life and the economy. This concern has therefore warranted development of research programs geared towards curbing the disease and reducing hospitalization and readmission rates. The articles reviewed in this research brings into view the defining aspects and the risk factors that are associated with heart failure. The findings will then provide an evidence-based practice and implementation plan that seeks to evaluate the existing intervention strategies and the efficacy of heart failure treatment means. This project will not only define the drug related treatment and management options but also the kind of policies and organizational strategies that can effectively make it possible for clinicians to research on best practices in healthcare.

Keywords: congestive heart failure, readmission rates, discharge plan

Congestive Heart Failure

Congestive heart failure is a leading cause of hospitalization among adult patients in developed countries. Improvement of healthcare quality thus lies upon prioritizing the reduction of early hospital readmissions, in this case, less than 30 days. Reports have since indicated that the condition also presents with it very high hospitalization rates (Ponikowski, Voors, Anker, Bueno, Cleland, Coats, and Falk, 2016). The estimated prevalence of heart failure in a sample population proved to increase as the cohorts aged (Ambrosy, Fonarow, Butler, Chioncel, Greene, Vaduganathan, and Nodari, 2014). The Agency for Healthcare Research and Quality in the US has acknowledged that readmission rates are often attributed to poor coordination and continuity among treatment providers.

A study conducted by a group of researchers aimed to synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention measures geared towards the condition. It also analyses the readmission rates by investigating the variables, self-monitoring, lifestyle changes and routine care accorded by primary caregivers (Leppin, Gionfriddo, Kessler, Brito, Mair, Gallacher, Wang, Erwin, Sylvester, Boehmer, Ting, Murrad, Shippee, and Montori, 2014). From the literature materials reviewed on the rates of readmissions and the prevalence of the disease, various studies were conducted to among which are; retrospective trials, cross-sectional studies and various other studies which gave informative statistics on the disease. The literature reviewed focused on monitoring the patient over a period of time between 30 days to 180 days after discharge.

The healthcare management sector has experienced immense advancement in healthcare measures and technological innovations geared towards treatment and management of heart failure. However, there has not been an effective discharge plan that will enable effective heart failure management as it still remains to have high hospitalization and re-hospitalization rates. This trend has been experienced among the aged population and especially those aged 65 years and above. The high rates of hospitalization presented by the prevailing situation in healthcare management have also created within the health sector and the entire nation a huge economic burden. Studies show that nearly 20% of discharges are followed by an adverse event within 30 days majorly due to improper treatment patterns, insufficient providence of necessary follow-up care and lack of compliance among the patients. This then leads to increased readmission rates in CHF among patients who had earlier been primarily diagnosed with CHF. The study, therefore, seeks to establish ways in which healthcare management can provide within itself effective discharge plan while comparing routine care and patient self-care practices.

The Spirit of Inquiry Ignited

Heart failure is a rising problem causing a burden to the healthcare sector. It has been found to be the leading cause of hospitalization and readmission and thus sparking a lot of concern to clinicians and healthcare professionals. The disease has been given high priority by both researchers, stakeholders, and the clinicians especially on ways to reduce re-hospitalizations through the provision of best healthcare practices. Healthcare professionals need to identify with the use of evidence-based therapies for heart failure management so as to ensure that there is a preferable choice of use of new ideas and development of new strategies to effectively reduce or rather prevent readmissions. All professionals in health management should in all circumstances walk together and offer particular attention to ensure that quality care is provided to congestive heart failure patients.

The PICOT Question Formulated

The PICOT question formulated for this study is: In patients 65 years and older who have been discharged after hospitalization with congestive heart failure (P), does an effective discharge plan (I) compared to routine care (C) influence readmission rates (O) over 30 days after discharge (T)?

Search Strategy Conducted

The project will rely on literature search that is found on scholarly resource database on heart failure focused articles about aged patients. The databases that were analyzed for evidence on heart rates were; Cochrane Library, Google Scholar, SU Library, PubMed, PMC, DynaMed, and TRIP Database. The search strategy employed included the use of keywords in search of relevant articles. The keywords used included; congestive heart failure, Readmission rates, Effective discharge plan. To refine the search results, limits features were used to provide for more relatable, peer-reviewed and open access full-text articles. PMC generated 783 articles, PubMed generated 3 articles Cochrane Library generated 10 reviews, DynaMed generated 10 articles and SU Library Search generated 230 articles related to my study topic.

Critical Appraisal of the Evidence Performed

Various articles were reviewed to evaluate the evidence linked to a reduction in hospital rates and interventions put in developing best practices in the discharge process. Koelling, Johnson, and Cody (2005) conducted a randomized controlled trial with a population of 223 in patients with systolic heart failure with CHF to compare the effectiveness of the usual discharge process with in-person education. The patients were then followed up over a period of 180 days to obtain clinical data on symptoms and self-care practices. The comparison in this study used multiple regression analysis to identify the confidence level of the variables used and the relationship that defines them. The study was able to demonstrate the effectiveness of patient education program in comparison to the usual discharge process. After 180 days of post-discharge, patients in the intervention group had a lower risk of readmission (readmission rate, 0.65; 95% confidence interval [CI], 0.45–0.93) (Koelling, Johnson, Cody, & Aaronson, 2005).

A randomized trial by Leppin, Gionfriddo, Kessler, Brito, Mair, Gallacher, Wang, Erwin, Sylvester, Boehmer, Ting, Murrad, Shippee, Montori, (2014) to investigate the effect of interventions on all-cause or unplanned readmissions within 30 days in comparison to adult aged patients admitted to the hospital for a medical or surgical cause for more than 24 hours and then discharged to home. This study sought to synthesize the evidence of the efficacy of interventions to reduce early readmissions and identify intervention measures geared towards the condition. It also analyses the readmission rates by investigating variables; self-monitoring, lifestyle changes and routine care accorded by primary caregivers. Despite the fact that this study is prone to biases, there is a consistency of examination of trials and thereby providing a great chance towards fulfilling the study needs. In the 42 trials that were examined, the interventions that were assessed proved that it could prevent early readmissions with a confidence interval of 0.73-0.91 and a pooled random-effects relative risk of 0.82 presenting a 31% chance. The study used a post-hoc regression model which showed the incremental value in providing comprehensive, post-discharge support to patients and caregivers. The intervention group with a chance of 0.001, a chance of 0.05 and a chance of 0.04 were respectively 1.4, 1.3 and 1.3 times more effective than other interventions.

A retrospective study aimed at examining demographic variables and etiology among participants suffering from heart failure provided ample evidence for the burden of preventable re-hospitalization for decompensated heart failure in the elderly. This study, however, reels from inadequate or poorly conceived medical therapy which was not considered. The dietary salt and fluid excesses could also not be quantified. Among the 102 cases of adult aged patients, preventable and unpreventable re-hospitalizations were investigated. This showed that almost 55.5% of the cases studied were preventable and it all relied on the patient’s lifestyle and their compliance to drug treatment usage (Ogbemudia & Asekhame, 2016).

The relationship between missed nursing care and hospital readmissions was analyzed through cross-sectional examination. A total of 160,930 patients with heart failure in 419 acute care hospitals in the US were examined. This showed that missed care is an independent predictor of heart failure. The study inferred the improvement of the working conditions of clinicians as a means to improve patient’s health and thus reduce readmissions.

Ong, Romano, Edgington et al (2016) completed a random study on 1437 participants with the median age being 73 years. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission but there was a significant difference in the 180-day quality of life between the intervention and usual care groups (Ong, Romano, & Edgington, 2016).

Evidence Integrated with Clinical Expertise

Studies have shown that readmission rates are associated with frequent lack of complete patient information, blood pressure monitoring, tobacco use among the patients and lack of compliance to the required lifestyle (Carthon, Lasater, Sloane, & Kutney-Lee, 2015). The study reports on a higher readmission rate on adult patients in whose blood glucose levels were high when compared to the others who were not readmitted. The patients who were readmitted were also likely to be suffering from diabetes and coronary artery disease (Deek, Skouri, & Noureddine, 2014).

Various studies have since been performed to study the readmission rates for congestive heart failure disease and its relation with other heart conditions. The observation period used in this study effectively matches the periods used by other researchers on the same topic. Although the readmissions rates differ slightly, this study in comparison with other former studies points to similar conclusions and risk factors. Primary care is an important aspect of the treatment and management of heart failures. Proper symptom assessment and home healthcare plays a major role in the management of adult patients with congestive heart failure as they are prone to other related heart conditions. The study, therefore, points out the essence of healthcare providers and primary caregivers in the management of the disease and the patients.

Evidence-Based Practice and Implementation

The EBP, Evidence-Based Practice, model developed relies on three external factors that are all geared towards the reduction of readmission rates. These factors include; Patient’s values, discharge process, and research evidence obtained which can be implemented in the project. The symptoms that are associated with heart failure include dyspnea, persistent cough, irregular heartbeats, angina pain, edema and fatigue. Heart failure is then categorized in different classes, class I-IV, in terms of the symptoms experienced. This classification was dubbed by New York Heart association functional classification system. Ejection fraction is thus a measurement tool to assess the condition of the heart with normal, preserved, and reduced ejection fraction implying normal, diastolic and systolic heart failure respectively. The readmission rates will be an independent variable which will thus be determined by two explanatory variables: discharge process and patient’s lifestyle.

Implementation that comes with EBP is thus difficult and requires new complex strategies and systems. As much as it will involve use of medical related practices, health professionals also need to understand the dynamics associated with leadership, organizational structures and the changing environmental patterns. The use of EBP as a tool for quality healthcare delivery dates back its first use in the fatality of the English soldiers in 1850s. A nurse, Florence Nightingale, charged with treating and taking care of the medical needs of the soldiers used this clinical practice model to offer medical support to the soldiers injured in the war. From the data that were collected and analyzed, she was able to make informed choices and decisions on how best she could improve sanitary conditions and thus reduce mortality among the injured soldiers. This experience has motivated the use of research in clinical nursing and medicine from then on.

Implementation of this program has been faced with a lot of challenges which include but not limited to insufficient time to conduct research and organizational policies developed to guide nursing practice. Most of the nurses still continue to use traditional means of healthcare delivery due to lack of the realization that they can make easy and informed healthcare decisions through analysis of research materials. In most instances, however, they are limited by reliable databases able to review a health matter at hand. The stakeholders in the health sector are therefore provide the needed expertise, policy development and a good environment where nurses can be able to practice and provide sustainable medical practice.

The efficiency which nurses have in the dispensation of their duties is duly increased through the use of EBP. The kind of care which heart failure patients need to receive can be made easier through the knowledge from research. Innovative methods in healthcare and technological changes in health sector requires the use of current nursing practices so as to keep up with the changes in the environment (Association, American Nurses, 2018). Not only will this reduce the time used in treating and managing heart failure patients but also creates an avenue where clinicians can have confidence in the methods used. The confidence that is developed from this can also motivate nurses to research more about the condition and even develop counter measures which are not only effective but also preserves the quality of life of the patients.

Leaders and hospital management also have a great task in ensuring the advancement of research in practice by provision of appropriate support to clinicians. The management can encourage or inculcate an EBP culture among its nurses by providing research centers, organizing research workshops and seminars, and developing research support pools where nurses can easily find valid information applicable for practice. To curb the issue that is associated with lack of sufficient time, the management can give more time to nurses outside their busy nursing schedule so that they can involve themselves in finding and reviewing available literature and find ways in which they can utilize the research results in day-to-day management of various conditions. The time which they are accorded, if used well, will also help those involved to be more knowledgeable about EBP than they were before involvement in the program. The knowledge pools can also come in handy as it creates a medium where they can share information with the peers on the subject matter (Fink, Thompson, Thompson, & Bonnes, 2005).

Johns Hopkins Nursing Evidence-Based Practice Model, JHNEBP, is lauded as a strong tool in solving problems in healthcare. It creates a medium of problem solving and offers a decision-making platform that is essential in nursing practice. The tools that are assimilated in the model are easily applicable and are also user friendly. This model is developed by use of three steps dubbed PET, practice question, evidence, and translation. This model is developed in a sense that it is able to incorporate latest research findings and best practices in patient care and in health sector as whole (Dearholt & Dang, 2017).

Merits

Organizational support

Prior experiences with EBP models

Readiness of clinicians to apply EBP

Clinical Expertise

Learning experience

Operational Performance

Inquiry on the organizational culture readiness for EBP

The readiness to apply EBP by the clinicians

Implementation and translation of the EBP

Reduced readmission rates

Evidence evaluation and action plan

Appraisal of the EBP implementation plan

Barriers

Lack of Knowledge

Insufficient time

Insufficient resources

Lack of guiding organization

Practice Improvement

Implementation of PET Management

Figure 1. EBP model, PET management

In this model, the essential part is in the PET management where the initial EBP question is formulated and thus involvement of the team leaders and the members. The first stage of implementation, therefore, will involve definition of the problem, identification of the stakeholders, determination of responsibilities and scheduling of the meetings. The evidence integration and synthesis will include searching for the evidence, appraisal, summarising, synthesising and development of recommendations. The translation will now be dealing with the feasibility of the project in terms of creation of an action plan, securing support resources, implementation and evaluating and reporting outcomes (Schaffer, Sandau, & Diedrick, 2013).

The detailed report on the use of EBP through this model therefore gives an understanding on how EBP can be applied in management of Congestive Heart Failure patients. From formulating the research question and the PICOT question, various steps need to be followed so as to fulfil the ultimate goal of EBP in nursing. The study used 5 different online resource databases using the keywords congestive heart failure, readmission rates and effective discharge plan. PMC generated 783 articles, PubMed generated 3 articles Cochraine Library generated 10 reviews, Dynamed generated 10 articles and SU Library Search generated 230 articles related to my study topic. An evaluation table was used to synthesise the evidence from the online resource database. The scholarly sources and articles related to congestive heart failure and readmission rates were evaluated to establish the strength, weaknesses, and the applicability of each article.

From the synthesised evidence from the evidence table, the age, gender, and body mass index of the patients will be analysed relating the period before admissions, after admissions and readmission cases experienced. Their etiology and diagnoses will also be put into perspective. Among the aged heart failure patients, recommendations based on reviewed literature will be applied to enable for a reduction of CHF readmissions. The recommendations which will be applied include patient education, pre-discharge risk assessment and establishment of dedicated heart failure clinics and response centers. The pre-discharge risk assessment in this case is essential for early identification of patients at high risk and thereby providing counter treatment or management. The steps given from the formulation of the research topic through to application of the evidence will be evaluated so as to identify their efficacy and effectiveness. This step will also seek to identify ways in which the steps may be improved in the future.

Outcome Evaluated

These studies show that nearly 20% of discharges are followed by an adverse event within 30 days majorly due to improper treatment patterns, insufficient providence of necessary follow-up care and lack of compliance among the patients. This then leads to increased readmission rates in CHF among patients who had earlier been primarily diagnosed with CHF. The fact that readmission rates are still high despite the interventions that have been used, the kind of healthcare and best discharge practices have been viewed as the sole course for reduced readmission rates for CHF. Some of the conditions are some of the factors that have contributed to heart failure. These conditions include; pneumonia, hypertension, anemia, and coronary diseases. Lifestyle followed by the patients and their drug compliance has also been the major cause for the increase in readmissions.

As much as the discharge process is viewed as the main cause for readmissions, patient lifestyle and compliance is also a major source of concern. Among the aged heart failure patients, recommendations based on reviewed literature will be applied to enable for a reduction of CHF readmissions. The recommendations which will be applied include patient education, pre-discharge risk assessment and the establishment of dedicated heart failure clinics and response centers. The pre-discharge risk assessment, in this case, is essential for early identification of patients at high risk and thereby providing counter treatment or management. This includes monitoring the diseases which have been related to cause heart failure.

The management of heart failure is, therefore, a mandate bestowed on all stakeholders involved in taking care of heart failure patients. These stakeholders include clinicians, and the primary caregivers accorded the task of taking care of the patients in times when the clinicians cannot access the patients. It is important to establish the link between these stakeholders and the patients toward achieving ultimate patient care.

Ground breaking research and technological innovation in clinical medicine has led to the development of effective drug treatments which has significantly led to a decrease in the rates of readmission. Heart failure has been established to be pharmacologically treated by use of a combination of drugs depending on the symptoms portrayed by the patient. Among these drugs are; renin-angiotensin system inhibitors and angiotensin II receptor blockers. Chronic heart failure patients have been treated by the use of Entresto; Novartis which was approved by US FDA in July 2015. The fast tracking of the approval was conceptualized by FDA due to its potential to treat this life-threatening disease (Fala, 2015).

Project Dissemination

The findings of the project will focus to use the intervention measures examined to bring a change in healthcare and heart failure management. The outcomes seek to assimilate evidence-based practices in the reduction of readmission rates in hospitals. The results obtained will be documented in formats which will enable for easy presentation and retrieval. To fully apply the recommendations and the best practices in clinical practice, the project will ultimately require participants, 65 years and above, ailing from heart failure who will then be put under two groups: intervention group and control group. The intervention group will be the group that will receive an effective discharge plan while the control group will be the ones put under the normal discharge process. The participants will then be followed up over a period of time, monitored and asked about their experiences so as to establish the effectiveness of the methods used in the process.

The feedback received will inform on the decision on whether the management option will be preferred, or another treatment plan is developed. To coordinate the intervention group, the project will use management option including patient one-on-one education, ensuring proper drug compliance through follow-up procedures and frequent patient visits. The participants will be followed-up over a period of 30 to 180 days from discharge to ensure proper reporting is reached at and also assess the quality of life after the end of the period of time.

Conclusion

The studies and literature reviewed show the burden that heart failure has had on healthcare and the economy as well. To avert the situation and develop an effective plan for patient’s wellbeing, it is important to understand what causes readmissions and deteriorating state of patient’s health. The findings have linked heart failure to many factors which include the patient’s lifestyle, compliance, and the advent of other related diseases. It is therefore important that individuals suffering from this disease are monitored and offered utmost care and discharge services so that their quality of life is improved and thus preventing readmissions rates translating to fewer expenses incurred by both clinicians and patients. Clinicians, additionally have to adapt to the changes in disease management and control through best research practices, technological innovation and use of effective drug treatment that have allowed for treatment of heart failure and other chronic diseases which have affected the heath sector.

Appendix

Appendix A

Evidence Table

Research Tool

Search Tips

Search Terms & Limits

Findings

Features

PMC

Use the filter feature

Choose the free full text articles

Look for the open access articles

Keywords Congestive heart failure, Readmission rates in older patients, Effective discharge plan Limits: Peer reviewed Less than 5 years old Full text articles Clinical trials

I found 783 articles with a good resource base to analyze readmission rates in aged patients.

PMC is a free health science citation & abstracts index from the National Institute of Health at the U.S. National Library of Medicine. The articles presented a resource base to do an in-depth analysis of the variables causing an increase in readmission rates. The database is very helpful as it primarily focuses on clinical trials and articles and thus correct account of events.

PubMed

Use the search option box and select PubMed

Filter recently published articles

Look for free full text journals

Keywords:

Congestive heart failure

Readmission rates aged patients Limits: 5 years

Free full texts

The research brought 3 articles with essential information about follow-up patterns and quality improvement strategies.

I found this database the best. It was the easiest to navigate and it has the most relevant articles related to my topic.

Cochrane Library

Use the Simple Search and the Advance Search Features from the Menu Browse reviews by topic

Keyword search: Congestive heart failure Rehabilitation Dietary plan Limits: Clinical answers and trials Less than 5 years old.

I found 10 search results all of which are clinical trial

The database has a complex criteria in the way information is achieved. The search option involves a series of inflexible features limiting a researcher to predestined headings. This therefore leads to finding most articles which are not suited and relevant to the study.

Dynamed

Use the Simple Search option on the homepage Browse reviews by topic

Keyword: congestive heart failure, Readmission rates, Effective discharge plan Limit: No limits can be applied to search results

The articles found in the database are 10 and focuses on heart failure, severity, and support measures for heart patients.

The database lacks articles with concrete evidence on heart failure and readmission rates. I didn’t find this database very useful.

SU Library Search

Use the advance search option to get to refine results

Keyword search: Congestive heart failure Limits: Peer reviewed Full text online Open access Medicine journals Less than 5 years old.

There are 230 articles on heart failure and readmission rates

This includes multiple databases which are very helpful in researching more specific topics. I found it very easy to use.

TRIP Database

Use the search option Refine results with the PICO option

Congestive heart failure Readmission rates Effective discharge plan

409

Helpful in providing comparisons detailed in the PICOT Question. Analyses in depth the research statement.

Appendix B

Evidence Synthesis

PubMed

Study#1

Study#2

Study #3

Study #4

Study #5

(p) Population

Electronic databases, scholarly experts, and reviewed bibliographies

1437 patients hospitalized for HF

223 systolic heart failure patients

102 heart failure cases

160 930 patients with heart failure in 419 acute care hospitals in the US

(i) Intervention

Assessed the effect of interventions on all-cause or unplanned readmissions within 30 days

Effectiveness of a care transition intervention using remote patient monitoring

One on one teaching process with a nurse educator

Preventable re-hospitalization

Missed nursing care

(c) Comparison

Adult patients admitted to the hospital for a medical or surgical cause for > 24 hours and discharged to home

All-cause readmissions among a broad population of older adults

Standard discharge process

Unpreventable re-hospitalization

Hospital readmissions

(o) Outcome

Relative risk of all-cause or unplanned readmission with or without out of hospital deaths at 30 days post-discharge

The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days

The addition of nurse educator-delivered teaching session at the time of hospital discharge resulted in improved clinical outcomes, increased self-care measure adherence, and reduced cost of care in patients with systolic heart failure

Multiple re-hospitalization for heart failure is a challenge for the elderly, but 55.5% of these readmissions are preventable. Poor drug compliance and pulmonary infections were the most common preventable participants

Missed care is an independent predictor of heart failure readmissions. Improvements in nurses’ working conditions may be one strategy to reduce care omissions and improve patient outcomes

(t) time

30 days

180 days

180 days

30 days

30 days

Appendix C

Evaluation Table

Citation

Design

Sample size: Adequate?

Major Variables: Independent/Dependent

Study findings: Strengths and weaknesses

Level of evidence

Leppin et al (2014)

Randomized trial

No

Early readmissions Patients admitted and discharged

Strength Consistency of examination of trials weakness Risk of bias

I

Ong et al (2016)

Randomized clinical trial

Yes

Readmission in older patients Care transition intervention

The variables could not effectively assess the readmission rates based on routine care and the standard discharge processes

II

Koelling, Johnson, Cody and Aaronson

Randomized, controlled trial

Yes

Clinical outcomes Discharge education Standard discharge process

Strength This is the first study to demonstrate the clinical benefit of a heart failure patient education program restricted to the hospital discharge time period.

I

Ogbemudia and Asekhame (2016)

Retrospective study

No

Demographic variables Etiology Participants of heart failure

Strength This study provides ample evidence for the burden of preventable re-hospitalization for decompensated heart failure in the elderly Weakness Inadequate or poorly conceived medical therapy was not considered, dietary salt and fluid excesses could not be quantified

I

Cross-sectional examination

Yes

Missed care Hospital readmissions

The cross-sectional examination explores a large population thus reliable information

II

References

Ambrosy, A. P., Fonarow, G. C., Butler, J., Chioncel, O., Greene, S. J., Vaduganathan, M., & Nodari, S. (2014). The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. Journal of the American College of Cardiology 63, 1123-1133.

Association, American Nurses. (2018). Magnet: Organisational Self-Assessment. ANCC. Carthon, J. M., Lasater, K. B., Sloane, D. M., & Kutney-Lee, A. (2015). The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals. BMJ Qual Saf 24, 255-263.

Dearholt, S. L., & Dang, D. (2017). Johns Hopkins Nursing Evidence Based Practice Model and Guidelines (Second Edition). Sigma Theta Tau.

Deek, H., Skouri, H., & Noureddine, S. (2014). Readmission rates and related factors in heart failure patients: A study in Lebanon. Collegian, 61-68.

Fala, L. (2015). Entresto (Sacubitril/Valsartan): First-in-Class Angiotensin Receptor Neprilysin Inhibitor FDA Approved for Patients with Heart Failure. American Health Drug Benefits, 330-334.

Fink, R. M., Thompson, C. J., Thompson, C. J., & Bonnes, D. (2005). Overcoming Barriers and Promoting Use of Research in Practice. The Journal of Nursing Administration, 121-129. Koelling, T. M., Johnson, M. L., Cody, R. J., & Aaronson, K. D. (2005). Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation 111, 179-185

Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K., . . . Montori, V. (2014). Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med, 1095-1107.

Ogbemudia, E. J., & Asekhame, J. (2016). Rehospitalization for heart failure in the elderly. Saudi Medical Journal, 1144-1147.

Ong, M. K., Romano, P. S., & Edgington, S. (2016). Effectiveness of Remote Patient Monitoring After Discharge of Hospitalized Patients With Heart Failure. JAMA Intern Med, 310-318. Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., & Falk, V. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). European Journal of Heart Failure, 891-975.

Schaffer, M. A., Sandau, K. E., & Diedrick, L. (2013). Evidence‐based practice models for organizational change: overview and practical applications. Journal of Advanced Nursing 69, no. 5, 1197-1209

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