Patient Management

Care Protocols

Care protocols, like medical and nursing procedures, allow staff to offer a consistent approach to managing clinic patients. Care protocols will allow caregivers to establish routines and govern tasks that are performed in the HF clinic as well as tasks that involve other hospital departments and outside agencies. Protocols ensure that key steps are taken to fill potential gaps in the system of care as the patient moves from clinic to hospital or from hospital to clinic.

The development of the following protocols may assist in enhancing the overall management of clinic patients:

• A protocol for patient referrals, which would involve two sub-protocols: one for patients who are referred for medical assessment, another for patients who are referred for patient education
• A protocol for discharge from hospital: this protocol would stipulate that a patient is either seen at discharge or at the clinic within 5 working days, or a telephone follow-up 2 days post-discharge will occur. This protocol should also describe clearly the sequence of events that occurs after discharge to ensure patients understand their care path
• A clinic notification protocol to outline when a patient has contacted the clinic about problems, and how those problems were dealt with. Guidelines for dealing with urgent vs. non-urgent calls
• A protocol for discharge from the clinic

Data Collection

Recent data suggest that, despite medical intervention, HF mortality remains high at a time when morbidity and mortality rates from other common cardiovascular diseases (such as myocardial infarction) are on the decline. Many heart failure patients experience frequent acute medical crises resulting in high hospital readmission rates and increased health care costs.

There is an urgent need to reduce mortality and morbidity associated with HF, reduce hospital admissions and readmissions, and improve patient management. HF clinics have been shown to be an effective alternative to inpatient management of this patient population.

Data collection, using a standard data-gathering tool, will allow practitioners to review and change practice patterns to enhance patient care and improve the quality of life for HF patients and their families.

In general, data collection will allow practitioners to monitor patient issues, measure clinical outcomes, track public health data, document the need for a HF clinic, secure clinic funding, and answer research questions.

Care Plan

A patient care plan, which specifies interventions and teaching done by staff and the anticipated patient outcomes, should be initiated and followed on all patients.

Such a care plan will ensure that patients receive optimum care and understand all facets of their diagnosis and long-term care. Care plans should be customized to meet the individual needs of each patient and should be developed with input from patients and family members.

Moreover, a care plan enhances communication and ensures continuity of care.