Telemonitoring changes the working practice of cardiac nurses

Apr 8 2009

The 9th Annual Spring Meeting of the European Society of Cardiology Council on Cardiovascular Nursing and Allied Professions (CCNAP), organised in cooperation with the Irish Nurses Cardiovascular Association (INCA), is being held at the Royal Dublin Society, Dublin, Ireland, on 24-25 April.

The meeting - considered by many to be the premier international event for nurses and allied health professionals - will show case the latest advances in practice, education and research. The 400 plus delegates expected to attend from 26 different countries, will have the opportunity to hear wide ranging sessions covering all aspects of cardiology, including enhancing self care in heart failure populations, managing patients with ventricular assist devices, sudden cardiac death, hypertension, angina, and adult congenital heart disease, and improving primary and secondary prevention.

The theme of this year's meeting is "Addressing the Challenges in Cardiovascular Care", with sessions exploring particular challenges of cardiovascular practice in the modern era, including diabetes and metabolic syndrome, behavioural change, and adherence to treatment. Sessions geared towards the practical management of cardiovascular care in daily situations will include how to incorporate guidelines into practice, take a cardiac history, improve assessment of heart sounds and interpret echo cardiograms. One innovative aspect of this year's meeting is the opportunity for health professionals to hear patients' personal perspectives on experiencing an implantable cardioverter defibrillator (ICD) storm, and having a ventricular assist device as a bridge to transplant.

"The Spring Meeting is about improving cardiovascular care, and addressing the challenges we face, such as the rapid development of knowledge and technology, and the changing roles of nurses and allied health professionals," says Professor Christi Deaton, Chair person of the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP).

Mary O'Connor, President of the Irish Nurses Cardiovascular Association, who is co-hosting this year's meeting, adds: "The meeting offers an invaluable opportunity for health professionals to network and meet with international colleagues to find out about the different ways of doing things. It allows best practice to be shared and will hopefully give delegates a lot of new ideas that they can introduce into their own clinical practice."

At the meeting more than 100 abstracts will be presented in poster, moderated poster and oral sessions reporting original research and clinical projects by nurses and allied health professionals. One such abstract by Ivonne Lesman (Groningen, The Netherlands) demonstrates that heart failure patients with new onset depression are significantly more likely to be readmitted to hospital (abstract 90082). The study, says Lesman, demonstrates the importance of screening for depressive symptoms in heart failure patients.

"We hope that the presentation of high-quality research will encourage more nurses and allied professionals not only to read and review research, but also to conduct more well-designed studies that build evidence for practice," says Professor Deaton.

Patients welcome telemonitoring

Telemonitoring is just one example of the cutting edge technology that is becoming integrated into every day cardiology practice. "Until now telemonitoring has largely featured in research trials, but this technology is on the cusp of becoming mainstream, and likely to result in a major change to the working practices of heart failure nurses," says Jill Riley, from the Royal Brompton Hospital, (London, UK), who is speaking in Friday's session exploring how telemonitoring can be used to enhance the self care of heart failure patients.

Telemonitoring, where telecommunications equipment is installed into patients' homes, enables a higher proportion of people with heart failure to be monitored by specialist services. Information on weight, blood pressure, heart rate and oxygen saturation is transmitted down the phone line on a daily basis, with patients asked to answer "yes" or "no" to questions about breathlessness, orthopnoea (shortness of breath when lying flat), dizziness and ankle swelling. Any change in vital signs triggers an alert to the heart failure specialist nurse who follows up with a telephone call and may recommend life-style or medication advice or suggest medical review.

"Telemonitoring is particularly helpful in heart failure where the condition of patients may change and nurses can identify those who need the most help. However it also helps teach patients how to live with and self-manage their heart failure," says Ms Riley, who has been interviewing patients who took part in a telemonitoring trial about their attitudes.

The answers showed that patients are extremely positive about their experiences. "They're reporting that telemonitoring helps them to feel more in control and empowers them to take better care of themselves" says Ms Riley.

Strategic challenges for Primary angioplasty

In Friday's session, exploring challenges in revascularisation, Professor Tom Quinn, from University of Surrey (Guildford, UK), will focus on the impact that primary percutaneous coronary intervention (PCI) is having on nurses and allied health professionals.

Primary percutaneous coronary intervention, also known as primary angioplasty, is a technique carried out in specialist centres, where a fine catheter (tube) is passed, under local anaesthetic, from an artery in the leg or arm into the blocked heart artery. An inflatable balloon is then passed through the catheter, and inflated to reopen the artery. Both ESC and American guidelines have identified primary angioplasty as the 'gold standard' treatment for patients suffering from ST elevation myocardial infarction, better known as STEMI, a type of heart attack caused by a prolonged period of blocked blood supply, leading to characteristic changes on the electrocardiogram (ECG). Studies have shown that PCI leads to better long-term outcomes for STEMI patients, with lower mortality risk. Fewer strokes and reduced risk of suffering a further heart attack, compared to the traditional 'clot buster' treatment (thrombolysis) that has been the mainstay of hospital heart attack care for the past two decades. In some areas thrombolysis may be given by ambulance staff if travel times to a heart attack centre are likely to be very long, and research is continuing to identify the optimal strategy.

"More and more centres in Europe are offering primary angioplasty for STEMI with the result we're now entering a totally new era for treating heart attacks" says Professor Quinn. " We need to start thinking through the ways we are going to manage this revolutionary change, learning from the experience of countries, such as the Czech Republic ,where PCI has been widely available for several years."

First, he says, there will be strategic challenges for reconfiguring heart attack services. This will involve educating health care planners and purchasers so that they understand the evidence base for both health gains to patients and cost effectiveness. Education will also be needed for emergency staff, paramedics and the public. With a small minority of patients with chest pain actually suffering STEMI, well trained paramedics (in countries where doctors are not available on ambulances) hold the key to identifying STEMI patients rapidly and getting them to the correct facility. Members of the public will need to be educated about the need to call an ambulance quickly if heart attack symptoms occur, and also that travel to specialist heart attack centres, that may be some distance from their home, is safe and can improve outcomes. Realistically such specialist services cannot be provided in every community hospital.

Nurses working in emergency departments are likely to play a major role in navigating STEMI patients through the system, getting them to the cath laboratory as soon as possible (although direct admission from the ambulance to the cath lab saves time and is preferable if local circumstances permit). Cath lab nurses will need to develop strategies to provide patients and families with appropriate levels of information about the procedure during the very acute phase, while not delaying treatment. Additionally, with shorter hospital stay because of the more rapid recovery seen with primary angioplasty, cardiac rehabilitation nurses will need to develop systems for ensuring that patients get appropriate access to support after the acute event."Finally, health professionals working in community hospitals will need to be reassured that there's still plenty of acute cardiology to be provided outside the heart attack centre," says Professor Quinn.

"Take home pearls" in Cardiovascular Disease Prevention.

In a joint US and European session on "Global Cardiovascular Disease Prevention: a call to action", Nancy Houston Miller, from the Stanford Cardiac Rehabilitation Program (Palo Alto, California, USA), will provide tips on how cardiology nurses and allied health professionals can start to introduce behavioural skills training into their every day practice. "More and more health care professionals are finding that marrying psychological (behavioural) techniques with cardiovascular knowledge helps them to be much more successful in encouraging patients to adopt life style change, whether that be stopping smoking, starting exercise programmes, or changing dietary habits," says Ms Houston Miller, adding that such intervention is urgently needed since data shows adherence to medications is often only 50 % at the end of one year.

In her 20 minute talk on Monday, Professor Houston Miller aims to deliver some "take home pearls" that her audience can immediately start to introduce into their practice. The techniques to be described include advice on how to display empathy, techniques of asking open ended questions, how to most effectively deliver a one to three minute message, developing skills for goal setting and monitoring, and even how best to set up your office from the educational stand point.

"I'm also hoping to inspire more health professionals to consider enrolling in more programs to help them with behavioural skills training," she says.

One such course is the EUROACTION course, pioneered by Professor David Wood and Catriona Jennings, which uses nurse coordinated prevention, programmes to improve life style and reduce cardiovascular disease. Key to the success of the course is the fact nurses use behavioural techniques to address individual's particular problems, and get partners on board to reinforce the project. On 22 and 23 April, just prior to the spring meeting, EUROACTION is running a pre course meeting in Dublin on "How to set up and run evidence based preventive cardiology programme".