Het onderstaande abstract werd geaccepteerd voor de Poster Presentatie tijdens de International Care Pathway Conference 2012 in Amsterdam op 31 mei en 1 juni.
Crossboundary pathway chronic heart failure White-Yellow Cross Limburg (organisation for Home-Nursing) icw Jessa Hospital
Abstract submitted for: poster, oral.
Authors Names:Monique Reenaers, Brenda Aendekerk, Marie-Jeanne Vandormael, Ilse Gorissen, Monique Claes, Marita Houbrechts, Bert Van Hoecke.
Lead Author: Monique Reenaers
Job Title of Lead Author: Home care nurse with specialitus as palliative care, clinical pathways, heart failure.
Organization of Lead Author: White-Yellow Cross Limburg (WYCL)
E-mail of Lead Author: ...
Telephone number of Lead Author: +32498/58-30-19
3 Bullet points to summarize your abstract:
- Crossboundary character
- Chronic disease, heart failure: working with an endless circle of time intervals
- Continuity in communication from the hospital to home care and vice versa and maximum multidisciplinary cooperation all involved primary caregivers and aids.
What was the objective of the project:
Prevent re-admission into the hospital as well as optimize the quality of life of our patients and improve this by:
- A seamless transition from the hospital to home care and vice versa, continuity in communication and crossboundary cooperation in patient care.
- Maximum multidisciplinary cooperation by fully engaging all involved primary caregivers and aids.
- Raise therapy loyalty and insight into the pathology of the patient and his environment by directed follow-up, continuous health information and education by the nurse/dietician of the White-Yellow Cross Limburg (WYCL).
The 30-steps plan of the Belgian-Dutch Network Clinical pathways functioned as a guiding principle for this pathway by its implementation and follow through. Our working group ‘Chronic heart failure’, supported by the executive board and core group members cooperated with the heart failure nurse of the Jessa Hospital to implement and follow-up this pathway.
The data of the Time Task Matrix obtained via the clinical path compass form the foundation of our clinical path document.
Because this pathway is chronic and has a crossboundary character, we work with an endless circle of time intervals starting with hospital discharge to a first visit of caregivers WYCL over communication, follow-up and care by caregivers WYCL, to re-admission and again to hospital discharge.
During the pre-measurement on 2008, 60% of the heart failure patients were re-admitted to the hospital within a year of discharge. The average time between discharge and re-admission was 82.8 days [7-365]. During the post-measurement on 2010, 37% of the heart failure patients were re-admitted to the hospital over a timeframe of one year from discharge. The average time between discharge and re-admission is 141.4 days [35-331]. In addition, the number of repeated re-admissions (per patient) has decreased: in the pre-measurement this is 33.4%, in the post-measurement 10%.
During the testing of our circle, we discovered the need for adjustment for patients who need palliative care or who moved to a retirement home.
Today, november 2011, 89 patients are included through the pathway after post-measurement. Current results: 21,8% of the heart failure patiens were re-admitted to the hospital over a timeframe of one year from discharge. The average time between discharge and re-admission is 180 days (46-335). In addition, the number of repeated re-admissions per patient is 41,6 %
When implementing this care pathway it appeared that the transmural data as well as the chronic character of this pathology was sometimes too complex to be processed into a successful care pathway. However, by continuing to work step by step and start on a small scale, this is attainable. It is clear from our intensive cooperation with the Jessa Hospital that we, each from our own perspective, seek the same high-quality and efficient care for our patients. This increased the value towards the care for the patient as well as “networking”! The 30-steps plan has proved to be a good methodology for the development of this care pathway. As a result of the specificity of the home care, the same steps can be taken for a slightly different pathway.
One of the strengths of this care pathway is the way it keeps growing. Not only within the WYCL but also to other hospitals. This shows that the chronic ilness heart failure requires a good cooperation en a crossing of boundaries to provide our patients with the best possible care.
Another benefit of the pathway is the standardization of the proses within the WYCL, and the crossboundary networking which is unique for each partner the WYCL works with. To extend further our pathway we started cooperating with the hospital “ziekenhuis Oost-Limburg” from january 2011. This resulted, untill now, in 60 patients being guided by the pathway. Also other hospitals show interests in our pathway for chronic heart failure patients.
This experience encourages us to develop and implement more (crossboundary) pathways for other chronic diseases.
To be continued!