Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal
Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal
Abstract
A research proposal will be conducted to determine if implementing a heart failure program within the hospital will reduce 30-day readmission rates. Medicare is cutting reimbursements to the hospital for readmissions that occur within 30 days.  Implementing an intervention to reduce readmissions using the Iowa model of evidence based practice to promote quality care will be done.  A literature review determined that many organizations implemented a strategy to reduce 30 day readmissions and were successful.  A pilot study will be implemented within the organization to see if enrollment in a heart failure program reduces 30-day readmission rates.  A retrospective analysis will be compared to the pilot study to determine the outcome. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal 
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Research Proposal
The purpose of this paper is to conduct a research proposal using the Iowa Model of Evidence Based Practice to Promote Quality Care.  My research question is “Do heart failure patients that participate in heart failure programs see a reduced rate of 30-day readmissions?”  Pending the results of the research question, the change will take place at an organizational level.  The Iowa Model of Evidence Based Practice to Promote Quality Care is the change model that will be used to implement this research question.  “The Iowa Model has been revised to focus on implementation of evidence based practice at the organizational level” (Schaffer, Sandau, & Diedrick, 2012, p. 1202).  According to White and Spruce (2015), “Nurses find the Iowa Model intuitively understandable and it has been used in numerous academic settings and health care organizations” (p. 52).  There are multiple steps in the Iowa Model that a team must address to fully implement their research question.  This paper will propose a research to be conducted to determine if finding an intervention to prevent heart failure 30-day readmissions provides higher quality of care and decreased costs for the hospital as an organization.
Statement of the Problem
President Obama passed the Affordable Care Act in March 2010.  “This act penalizes hospitals with a high rate of patient readmission within 30 days of discharge with heart failure as the diagnosis” (Hobbs, Escutia, Harrison, Moore, & Sarpong, 2016, p. 145).  “Estimated costs of these 30-day readmissions in Medicare beneficiaries are in excess of $1 billion each year” (Banoff, Milner, Rimar, Greer, & Canavan, 2016, p. 172).  What can be done to help reduce the rates of readmissions?  “Heart failure is the most frequent reason for rehospitalization among cardiac patients; the current readmission rate for patients with heart failure is 40%” (Hobbs, Escutia, Harrison, Moore, & Sarpong, 2016, p. 145).  For Medicare patients alone, the 30-day readmission rate ranges between 22%-25%.  By 2030, it is estimated that heart failure will annually cost health care $70 billion (Hobbs et al., 2016).  If a hospital has a heart failure readmission rate above the national average, Medicare reduces reimbursement by 1% but it will gradually increase to reducing reimbursement by 3%.  This may appear to be a small percentage but annually heart failure readmissions can cost Medicare about $2 billion (Centrella-Nigro et al., 2016).  If the hospital is able to reduce the readmission rates of heart failure by implementing an intervention such as higher quality post discharge education or a heart failure program, then they can save money by reducing the rate of readmissions.   A heart failure program would be able to offer a range of services that would help the heart failure population avoid preventable readmissions by ensuring health care continuity and promoting the safe transfer of patients from hospital to home.  “One of the most effective methods to reduce costs caused by readmission is for healthcare providers to contact patients after discharge by telephone” (Hobbs, Escutia, Harrison, Moore, & Sarpong, 2016, p. 146).  A study was done that showed a lower rate of readmissions within 30 days just by telephoning the patient post discharge (Hobbs et al., 2016).  This telephone call to the patient could reiterate heart failure discharge education, evaluation of signs and symptoms, medication compliance, diet, weight control and support reassurance (Hobbs et al., 2016).   A nurse in the cardiology clinic or in the cardiac rehabilitation center can place the phone call to the patient.  Every day, the nurse can receive a computerized print out of recent heart failure discharges and then place phone calls out to the patients to see if they have any questions since discharge or if they are experiencing any symptoms.  The heart failure program would start at time of discharge by having the Pharmacist or medication technician review the discharge medication reconciliation to ensure that the patient is on the correct heart failure medications as determined by the guidelines of the Heart Failure Society of America.  Hospitals that implemented a higher quality discharge education with heart failure patients showed a reduced 30-day readmission rate.  A study done using heart failure discharge resources showed a 30-readmission rate of 5% when compared to 13% when using usual discharge protocol (House, Stephens, Whiteman, Swanson-Biearman, & Printz, 2016).  Another study that implemented core measures upon discharge showed an improvement in 30-day heart failure readmission rates by 2% (Gunadi et al., 2015).  Implementing a heart failure program that uses healthcare providers to contact the patients early on post discharge prior to any hospital follow up will help reduce heart failure readmissions and should be implemented.  This will financially affect the hospital if an intervention isn’t put into place.  Since the topic is financial data driven and a process improvement, it is considered to be a problem-focused trigger (White & Spruce, 2015).  This is important information to know on why a possible heart failure program would be a great intervention to reduce heart failure 30-day readmissions.  Not implementing an intervention to reduce the number of heart failure patients can affect the organization as a whole and associated with a cost factor so it would be considered a higher priority. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal
Forming a Team
An organization is composed of hundreds and sometimes thousands of employees.  Finding the right members for a research team is important because the research team is responsible for finding the best solution for that specific research proposal.  The members should have some type of relevance to the research.  “The composition of the team should be directed by the chosen topic and include all interested stakeholders” (Doody & Doody, 2011, p.662).  Since this research is focused on heart failure readmissions, possible team members would be the following: cardiologist, cardiac rehabilitation nurses, cardiac rehabilitation aide, pharmacist, telemetry nurse manager, cardiac step down nurses, dietitian, primary care physician, and/or social workers.  All these team members have direct contact with heart failure patients prior to admission, during admission, or post discharge.  Having a wide range of specialty areas will give the research different points of view.  “It is important to remember that including representatives for all personnel involved is the most successful approach to implementing evidence based practice because change is more successful when initiated by the personnel affected, rather than imposed by management personnel” (White & Spruce, 2015, p.55). Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal
Evidence Retrieval
Gathering evidence and research is the next step in the Iowa Model.  “The most important portion of this step is to form a good question (using the PICOT method) and then conduct a literature search for actual research studies that pertain to the question at hand” (Brown, 2014, p. 157-158).  A medical librarian can assist in the search, as well as using electronic databases like Medline, Cochrane, and/or Cinahl.  Clinical practice guidelines can also be used to search for the best available evidence.  The American Heart Association may have guidelines related to heart failure practice standards that should be implemented into the intervention as well.
Literature Review
            Methodology.
An electronic literature search was done using various databases to find pertinent journal articles, case studies, and/or reports that shed light on preventing heart failure readmission.  Proquest and CINAHL databases were used to search English, full-text, United States sources.  Key terms used to guide the search were heart failure, heart failure readmission rates, preventing heart failure readmissions, and heart failure programs.  The search provided over 10,000 journal articles.  Titles and abstracts were first reviewed to determine the significance to the topic being searched.  Articles that were published between 2010-2016 were included in search criteria.  The search didn’t produce much research pertaining to heart failure programs itself so the search was widened to include any type of professional interventions with heart failure patients done to reduce heart failure readmissions using the key words heart failure readmission prevention strategies.  The final sources were chosen based on if they discussed implementation of some of intervention that helped reduced heart failure readmission rates.
Grading the Evidence
All studies will have to be critiqued to ensure that the study is scientifically sound.  “Quantitative data is based on the process of deduction, hypothesis testing and objective methods in order to control phenomena with its focus on theory testing and prediction” (Doody & Doody, 2011, p. 662).  The research team will have to grade each article on its strength, weaknesses, sample size, region research was conducted, reliability, & validity, and risk-benefit ratio.  The team can decide for themselves how they want to go about grading the evidence (teams, singles, or together). With this particular research proposal, there aren’t many risks to the patients because chart review and implementation of an intervention that will possibly benefit their health will be conducted which will not cause harm to the patient. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal
Discussion.
A total of six sources were collected for the literature review that discussed reducing heart failure readmission and different strategies used and implemented within that study.  The literature review came up with many different strategies and techniques that are used to help prevent heart failure readmissions.  Two sources are systematic reviews (Hines et al., 2010; Hobbs et al., 2016) that examined multiple interventions that were done at various sites to prevent heart failure hospital readmissions.  One source is a national cross-sectional study that examined 594 hospitals that reported implementing key practices to reduce readmission rates (McClintock, Mose, & Smith, 2014). The fourth is a case study (Gunadi et al., 2015) that examined a pharmacy led intervention to reduce the heart failure readmission rate.  A quality improvement design (Kreifels & Tracy, 2016) was used to implement a heart failure management program to reduce heart failure readmission and the final source is a multi-site descriptive retrospective study (Centrella-Nigro et al., 2016) that examined six Magnet-designated hospitals and their methods implemented at reducing heart failure readmissions.
Multi-disciplinary intervention.
A multi-disciplinary approach was used in multiple sources (Hines et al., 2010; Hobbs et al., 2016; McClintock et al., 2014) that focused on telephone follow up calls, timely follow up appointments, and/or transitioning the patient from discharge to home and ensuring that home health care needs were addressed prior to discharge.  Hines et al. (2010) “Ideal transition to the home environment for patient with heart failure reduced 30-day readmission rates from 15% to 6%.  This consisted of identifying the patient’s needs and communicating and educating the family and patient on the patient’s care plan and making sure that the patient had a hospital follow up appointment made prior to being discharged.  According to McClintock et al. (2014) hospital readmissions were decreased by “14%-87% by incorporating outpatient interventions such as case management, tele-monitoring, home health, or heart failure clinics” (p. 431).  Patients in this study “Reported receiving education about salt restriction and exercise and adhering to the low-salt diet for a mean of 4.9 days and exercising for a mean off 2.2 of 7 days” (McClintock et al., 2014, p. 431) so it’s “critical to have a follow up appointment within days after hospital discharge”.  Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal .However, given this data McClintock et al. (2014) didn’t report any statistical data that would confirm their findings that an early follow up reduces hospital readmission rates for heart failure patients.  Hobbs et al. (2016) evaluated reviews of heart failure patients by telephone follow up calls with five of their sources and all found a decrease in hospital readmissions.  A small sample study was done in a rural Midwest location that utilized a heart failure management program (Kreifels & Tracy, 2016).  The program followed the American Heart Association and Institute for Health Care Improvement guidelines for heart failure management and nurses gave educational sessions to patients, explained the heart failure program, and scheduled hospital follow up within 72 hours to 7 days of discharge (Kreifels & Tracy, 2016).  There were no heart failure readmissions during the 12-week implementation of this program.
Pharmacy led intervention.
A pharmacy led intervention was done to see if there was improvement in heart failure readmission rates by revising a patient’s medication list and assuring that the patient was being discharged on the correct medications.  Gunadi et al. (2015) did a case study by having a pharmacist and two medication reconciliation technicians review a patient’s medications within 48 hours of admission and then again at discharge to assure “medication appropriateness and dosing, therapeutic duplications, omissions, and drug-drug interactions” (p. 1150).  Each patient was given a readmission complexity score that was based off of the following criteria: previous hospital readmission in past 6 months, ED visit within last 30 days, serum creatinine consistently above 1.5mg/dL, glucose consistently above 200mg/dL, change in functional status, presence of co-morbidities, and use of 7 or more medications (Gunadi et al., 2015). Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal. One point was given for each criteria met and the pharmacist would prioritize their patients based off the patients with the highest score.  The study showed a decrease in readmission rates from 17% to 15% but the hospital also increased their core measures compliance.  There was no statistical analysis done to determine validity or reliability.
Retrospective analysis.
A retrospective analysis was done to determine if physiologic, demographic, and/or psychosocial factors were associated with 30-day readmission rates for heart failure patients by examining electronic charts (Hobbs et al., 2016).  Thirty-seven different variables were examined against 30-day hospital readmission rates among six hospitals.  “Kendall’s Tau-b correlational statistic was used to compare the data” (Hobbs et al., 2016, p165).   This study resulted in that determining demographic, physiologic, and psychologic factors weren’t beneficial in determining which interventions are best to prevent heart failure readmissions.
Conclusion of literature review.
Limitations in this particular study were that not all resources used showed validity or reliability in their findings. Further research can determine if one specific intervention has a greater impact on reducing heart failure readmission rates.  More research can be reviewed when using a larger team.
Implementing the Evidence
This is the step where the team will have to decide if they are going to implement the change into practice.  Doody and Doody (2014) stated “The following criteria should be considered when determining whether research can be implemented into practice: (a) consistent findings exist from numerous studies to support the change, (b) the type and quality of the studies, (c) the clinical relevance of the findings, (d) the number of studies with similar sample characteristics, (e) the feasibility of the findings in practice, and (f) the risk-benefit ratio” (p.158).  If the majority of the criteria is met, then the team should plan to implement the change using a pilot practice.  The team will develop standards for their research question that will be used when implementing their pilot practice.  The studies that were reviewed for this proposal were consistent in the aspect that implementing some form of intervention for heart failure patients upon admission and/or discharge did prove to have a reduction in 30-day readmissions.  Not all resources reviewed were high quality because the majority of studies did not provide validity and reliability factors regarding their research.  The evidence provided by these studies is relevant for our research proposal because it’s guiding the team with various strategies that could possibly be implemented as an intervention to reduce heart failure readmissions.  All studies had similar sample characteristics because all the studies reviewed used heart failure admission/discharge patients as their participants.
Pilot Practice
In this step, the study question will be implemented into a pilot practice.  It shouldn’t involve the entire organization but for the sake of this specific research question on heart failure it will end up involving the organization because it isn’t possible to just implement the study in one unit or one department.  To see a change, the team will have to conduct an organizational pilot practice.  “The Iowa Model’s Implementation Guide suggests the following implementation strategies: create awareness, build knowledge and commitment, promote action and adoption, and pursue integration and sustained use” (White & Spruce, 2015, p. 55).  It’s important to gain acceptance across the entire organization. “This can be done through in-service education, audit, and feedback provided by team members.  The evidence needs to be diffused and should focus on its strengths and perceived benefits” (Doody & Doody, 2011, p. 663).  Patients that are going to be admitted with heart failure can be placed on one specific unit (cardiac step down or telemetry).  The pilot study can use the pharmacist on that unit to review medications on admission and on discharge to ensure that all heart failure patients are on the correct medications.  The primary care provider can ensure that the correct diagnostics lab work and tests have been ordered and if they are unsure than a cardiologist should be consulted.  A social worker should also evaluate the patient’s homecare needs upon discharge to see if home assistance or supplies will be needed after discharge. An example would be that a patient needs assistance with their mediations because they are noncompliant or needs transportation to their hospital follow up appointment.   Upon discharge, the unit secretary can all the patient’s primary care provider and/or the patient’s established cardiologist to make a hospital follow up appointment for the patient within seven days of discharge. The discharge nurse will also supply educational heart failure handouts and educate the patient and family member on heart failure symptoms to watch for, importance of medication compliance, special diet, daily weights, smoking cessation, and when to call the doctor or report to the emergency department.  Each day, the cardiac rehabilitation nurse will receive a computerized print out that will give the previous day’s heart failure patient discharge list.  This list can be generated by narrowing the patients that were discharged by their ICD 10 code for heart failure.  The cardiac rehabilitation nurse can make a phone call out to the patient to see how they are feeling since they’ve been discharge.  If the patient has any questions this is the time when the nurse will be able to assist them.  If the nurse is questioning the patient’s symptoms or doesn’t know the best solution for the patient’s problem she can contact the patient’s primary physician or their cardiologist and see what they recommend. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal
Ethical Consideration
Risks 
“The principle of minimizing risks and balancing risks and benefits is one of the most important components of the protection of research subjects and is included in all the major international research ethics guidelines” (Gufenas, 2006).  There won’t be any risks to patients directly because the research won’t directly affect patients.  The patient’s right to self-determination won’t come into effect because the patient isn’t actively participating in the study.  There will be a suggestion for participation in the heart failure program but it’s completely voluntary and will be part of the physician’s orders for better health care.  One could say that it’s a type of coercion because the role a physician plays over a patient.  The physician will order the heart failure program for the patient upon discharge just like a physician would order physical therapy or other rehabilitation.  No coercion is used.  There is a possibility that some of the participants may be of a vulnerable population.  Pregnant women, persons with cognitive impairment, and persons confined to institutions are all possible participants.  According to Grove, Gray, & Burns (2015), “The use of persons with diminished autonomy as research subjects is more acceptable if the following are true: (1) the research is therapeutic—that is, the subjects might benefit from the experimental process; (2) researchers are willing to use vulnerable and nonvulnerable people as subjects; (3) the risk is minimized in the study; and (4) the consent process is strictly followed to ensure the rights of the prospective subjects”.  In this specific research, the retrospective review of charts will be done (this will not harm or violate any patient rights) and also current medical record review Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal.  Patients will have the right to participate in the heart failure program and it will be ordered by their physician but strictly voluntary.  There won’t be any risk of permanent damage, unusual levels of discomfort, or even temporary discomfort.
HIPAA Concerns
This research will be done within a health care organization.  All researchers that are participating in the research will be bound by HIPAA regulations within the hospital setting.  Initially deidentification measures were going to be used which but researchers will need the admission and discharge dates which eliminates this option.  “De-identification is a helpful concept, but de-identifying is difficult, because HIPAA requires the elimination of 18 separate elements that could be used to identify the individual-including name, address, social security number, birth date, admission and discharge dates, and zip code” (Lebowitz, 2005).  However, upon every admission the hospital does have the patient sign a consent and authorization to disclose health information with the hospital setting.  Since the researchers will be within the hospital setting a HIPAA should not be violated.  HIPAA will also not be violated with the results of the research because patient’s identification won’t ever be disclosed.  The only disclosure from this research will be the relationship of heart failure readmissions without enrollment in a heart failure program and heart failure readmissions with enrollment in a heart failure program. Patient identity will never be disclosed. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal.
Informed Consent Components
“Informed consent is a process that protects human subjects and allows for voluntary, autonomous authorization by individuals who participate in clinical research” (Judkins-Cohn, Kielwasser-Withrow, Owen, & Ward, 2014, p.36).  The patients aren’t actively participating in this research and their identity will never be disclosed so informed consent won’t be needed.  The research is strictly a chart review that is examining data reports generated from those chart reviews. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal According to Kaczorowski, Sellors, Lemelin, & Hogg (2001), informed consent is not needed for chart reviews.
Evaluation
Once the research has been implemented and is in action there has to be constant evaluation.  Staff members should feel comfortable on giving their feedback on the pilot practice.  “The team members should be watching for deviation in practice or a decrease in the patient outcomes” (Brown, 2014, p. 158-159.)  Team members should compare baseline data with data after the implementation took effect to see if there is a significant change and to see if evidence contributed to positive patient outcomes (Spruce & White, 2015).  Barriers in the use of the implementation will have to be addressed to ensure that all staff feel confident with the change.  Since this research is looking at a 30-day readmission rate it may have the sleep effect; “benefits may only become apparent after a considerable period of time” (Doody & Doody, 2011, p. 664).  Various interventions were done with heart failure patients post hospital discharge.  Heart failure programs weren’t identified specifically but incorporating an intervention with heart failure patients between admission, discharge, or outpatient proved to show success rates in reducing 30-day heart failure readmission rates. Iowa Model of Evidence Based Practice to Promote Quality Care heart failure Research Proposal.  When the intervention is in place, any heart failure patient that is admitted to be tagged to determine if they are a 30-day readmission.  If they are a 30-day readmission, then their chart will be reviewed to determine what failed.  Maybe the patient never answered when their discharge follow-up call was placed and the nurse never was able to assess the situation, the patient didn’t make their hospital follow up appointment with their doctor, or all discharge needs weren’t met.  The patient will also be interviewed in a non-interrogation way during the admission process to find out more of their health history to see if their readmission could have been prevented and then the team can brainstorm solutions on how to fix that problem for the future.  The intervention can be ongoing with critiques and alterations made by the research team to that best meet patient and healthcare needs.  Employees can be made aware of this new process by way of email, reiterated in departmental meetings, and also a competency to determine they understand why it’s being implemented.  It’s important that all staff is made aware of these changes because staff float from unit to unit and there needs to be a consistency of care in case nurses are floated to the pilot unit.
Conclusion
A heart failure discharge intervention does need to be implemented to help reduce 30-day readmissions.  From the studies that were reviewed there are different strategies that can be implemented within an organization to reduce the readmission rate.  The research team will use the Iowa model to implement this change.  The Iowa Model of Evidence-Based Practice to Promote Quality Care is a great change model to implement a change within an organization.  “The model considers input from the entire organizational system, including patient, providers, and organizational infrastructure, and involves nurses in each of the steps and also allows a practice change before final implementation” (Schaeffer et al., 2012, p. 1202).  There is a sequence of steps that make it easy for all team members to follow.  The Iowa Model will be able to help the organization implement clinical practice guidelines.  With the help of the entire research team, employees being made aware of the change and reasons behind the change, a successful intervention can take place.
 
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