Transitional care in Heart Failure: a best practice implementation project

Introduction: Considered a pandemic throughout the world, heart failure (HF) is the most prevalent heart disease(1) and is associated to several comorbidities, low quality of life(2-4), frequent hospitalizations and high costs to the health system(5-6) . It is up to the professional nurse to facilitate the continuity of care in any context. Transitional care (TC) of the person with HF, from hospital to home and/or clinic, includes interventions that encompass the supervision, monitoring and management of signs and symptoms and the promotion of adherence to the therapy to improve quality of life and reducing readmissions(7-8). General objective: Implement the best evidence on care to support the transition of people with HF from hospital to home/outpatient care. Method: This is a project of implementation of the best evidence through the methodology developed by the Joanna Briggs Institute (9), using the tools Practical Application of Clinical Evidence System (PACES) and Getting Research Into Practice (GRIP). The project implementation is divided into three phases: 1) composition of the project team and conducting a baseline audit to evaluate compliance with conformity to six criteria based on the best available evidence (the nurses had training on TC in HF; patients/caregivers had training on transitional care from the hospital context to homecare/outpatient treatment; individual plans for hospital discharge were developed and documented in medical records and documented in a handbook; TC was given in a personalized way in order to interlink the hospital context to the homecare/outpatient one; there was communication between the hospital and outpatient context nurses; the post-discharge follow-up occurred so that it could include phone or outpatient monitoring) (10); 2) implementation of the best practices based on scientific evidence to improve/increase the level of compliance with the audited criteria; 3) Follow-up audit for reassessment of the same criteria audited in the baseline audit. The study is being developed in the Cardiology Outpatient Clinic and the HF outpatient facility of a hospital specializing in cardiology in São Paulo-Brazil. The sample consists of 12 nurses from the two sectors referred above, and discharged patients with HF/caretakers, referred for outpatient/homecare monitoring (10 participants in each audit). Expected results: The baseline audit results will be assessed by the project team to propose feasible strategies in the scenarios for the adoption of practices that improve compliance with the audited criteria. The project team will begin this work discussing the feasibility of the following strategies: the implementation of telephone contact with the patients who will be approached during the follow-up audit in intervals of seven, 14 and 30 days after hospital discharge, with content to be defined from the collected data, and an educational program for nurses addressing TC for people with HF. The objective of the adoption of best practices in TC is the improvement of the capacity for self-care, control of symptomatology of patients with HF, and reduction of readmissions, as well as keeping the nurses knowledge about TC in HF updated to provide a quality- and evidence-based nursing care.