Development of a nurse-led follow-up pathway for patients discharged from cardiology unit: the DIMACC project
Authors: Pradovera E , Avanzini F , Achilli F , Amodeo R , Carbone S , Colombo L , Corticelli A , Nava L , Paone M G , Saltafossi D , Santambrogio M , Di Giulio P 
Published: July 2023

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Novartis

Background

The first year after hospitalisation for Acute Coronary Syndrome (ACS) or Acute Heart Failure (AHF) is the most critical period, with the highest incidence of complications and re-hospitalisations. Multiple epidemiological studies have documented that while hospital mortality in the acute phase has gradually decreased, the mortality trend after discharge remains stable or even increased. These trends may be an expression of inadequate follow-up and poor patient involvement, resulting in poor control of risk factors, and suboptimal adherence to treatments.

Aim

To present a protocol design for a quality improvement intervention regarding a supported discharge pathway for ACS and AHF patients.

Methods

The construction of the DIMACC protocol is based on the Plan, Do, Check, Act methodology. Pre-intervention phase: A research project has been developed to introduce a supported discharge pathway from Cardiology wards. The objective and motivation for the change from the existing situation were defined and supported by the theoretical model and international guidelines. Development of the study tools: This phase included the Consensus Conference held with the local institutions, the University delegation, the Head Manager of the District, doctors and nurses, where the actors shared intentions, thus proceeding to their formal approval. Data collection instrument was set. Intervention phase: The group identified strategies to ensure the best possible dissemination of the procedure and the professionals' adherence. A data processing company was involved, which created an online platform to collect the study data. Recruitment within the pilot study started in November 2022.

Results

The DIMACC project is a PROSPECTIVE OBSERVATIONAL STUDY evaluating the feasibility and performance of a quality improvement intervention on patients discharged from Cardiology following admission for ACS and AHF. The study consists of TWO phases. Phase one aims to implement a structured follow-up in the first year after discharge, with examinations and visits planned according to the severity of the single case. As primary endpoint, there is the achievement of clinical objectives defined on discharge, based on ESC guidelines, improve disease control and reduce the number of admissions to the Emergency dept. and re-hospitalisations. In the second phase, the group plans a series of structured educational interventions held by community nurses care to promote patient engagement and further reduce the elements listed in phase one.

In the first two months of the pilot phase, 41 patients were included, with a progressive increase compared to total admissions for ACS or AHF (41% in November and 72% in December).

Conclusions

This study will generate essential knowledge on CVD patients' experiences and self-empowerment. Findings will be of considerable interest and benefit to many health and care organizations beyond the immediate community of interest.