Nurse Led Transitional Care Model in Cardiac Surgery

Study Overview
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Brief Summary
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To evaluate the effectiveness of Nurse Led Transitional Care Model (TCM) on the functional autonomy, quality of life and rehospitalization rates of elderly patients undergoing open heart surgery.

Detailed Description
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Rate and number of successful cases in open heart surgery has been increasing due to the advances in medical technology and surgery. To improve patient convalescence results and reduce rate of post-discharge readmission to hospital and unplanned post-discharge rehospitalization, home-care and follow-up process of patients should be managed successfully. A total of 66 elderly patients who agreed to participate in the study between November 2017 and December 2018 were randomly assigned to the intervention (n: 33) and control (n: 33) groups. Patients in intervention group were given care based on the TCM until the post discharge 9th week starting from date of hospitalization. Patients in control group were given standard care services. Functional autonomy and quality of life levels of patients were evaluated at admission to the clinic and at the post-discharge 9th week whereas their repeated admission rates to the clinic and re-hospitalization rates were evaluated at post discharge 2nd, 6th and 9th weeks and finally 6 months. The CONSORT checklist was used to check the procedure.

Official Title
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The Effects of Nurse Led Transitional Care Model on Elderly Patients Undergoing Open Heart Surgery: A Randomized Controlled Trial

Conditions
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Nursing Care, Quality of Life, Transitional Care

Intervention / Treatment
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* Procedure: Nursing care based on the Transitonal Care Model


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: be hospitalized for the first time and for elective open heart surgery; have no other surgical intervention other than an open heart surgery, have no psychological and mental disorders, have no major chronic problems such as kidney problems, neurological problems or cancer, be able to speak Turkish, be available to be communicated by phone, provide consent to participate in the study, live at a maximum distance of 50 km from the hospital (for easy access during post-discharge follow-up visits). Exclusion Criteria: ask to leave the study, be exposed to a disease or trauma that may affect his/her functional autonomy during the study, die throughout the study

Ages Eligible for Study
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Minimum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Randomized controlled intervention study with a parallel group in a pretest-posttest design
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: ''Standard Care''<br>''Standard Care'' group were given standard care services. | |
| Experimental: Transitional Care Model<br>Transitional Care Model group were given care based on the Transitional Care Model until the post discharge 9th week starting from date of hospitalization. | Procedure: Nursing care based on the Transitonal Care Model<br>* Nursing care carried out in collaboration with a multidisciplinary team in line with Transitonal Care Model for elderly patients who have undergone open heart surgery<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from Baseline(up to 24 hours after the admission) in functional autonomy on the Functional Autonomy Measurement System (SMAF) at 9th week after discharge. | The Functional Autonomy Measurement System (SMAF) is a validated, self reported instrument assessing 25 functions of the individual including daily life activities, communication and mental functions. Possible scores range from 0 to -87. A total score below -5 obtained by the elderly person indicates that the patient is at the risk of losing his/her functional autonomy. Change = ( Week 9 after discharge score -Baseline score) | Baseline(up to 24 hours after the admission) and Week 9 after discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from Baseline(up to 24 hours after the admission) inquality of life on the SF-36 Quality of Life Scale at 9th week after discharge. | The SF-36 Quality of Life Scale is a validated, self reported instrument consists of 36 items in total, assessing the health status in eight aspects namely; physical function (10 items), social function (2 items), role limitations due to physical problems (4 items), role limitations due to emotional problems (3 items), mental health (5 items), energy/vitality (4 items), pain (2 items) and overall health items (5 items). Each part of the scale is evaluated differently and hence does not have a total score that can be calculated. Change = ( Week 9 after discharge score -Baseline score). | Baseline(up to 24 hours after the admission) and Week 9 after discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Transitional Care Model, heart surgery, nursing care, autonomy, quality of life, elderly