The Effect of Music on Postoperative Agitation, Pain, and Opioid Use among Patients Undergoing Total Knee Replacement.

BACKGROUND: Postoperative pain and agitation is an ongoing issue among patients undergoing total knee replacement (TKR). Use of complementary therapies such as music may improve outcomes when combined with medical therapy. AIM: The purpose of this quality improvement (QI) initiative was to evaluate postoperative use of classical music among adult patients who have undergone TKR on reported agitation, pain, and opioid use. DESIGN: A prospective evidence-based QI initiative. SETTING: A midwestern hospital post-anesthesia care unit. PARTICIPANTS: Postoperative patients who had undergone TKR. METHODS: Classical piano music was played postoperatively using an MP3 device. Adult patients who were undergoing TKR were consecutively offered music during their recovery period in the PACU. Agitation was measured using the Richmond Agitation Sedation Score (RASS). Patient perceived pain was measured on a scale of 0-10 with 0 being no pain and 10 being extreme pain. Opioid use was measured using the morphine milligram equivalents (MME). FINDINGS: A total of (n=40) patients received music and (n=50) patients received standard care without music. RASS was significantly lower in the music group than in the baseline non-music group X2 (1, N = 89) = 17.8, p < .001. Patient reported pain scores were significantly lower in the music group, 3.98(SD = 2.71), compared to the baseline non-music group, 6.27(SD = 2.60). Opioid use was also significantly decreased in the music group to MME 9.51(SD = 8.62) compared to the baseline non-music group 13.38 (SD = 9.71). CONCLUSION: Music is an effective nonpharmacologic intervention in decreasing agitation, pain, and opioid use among patients undergoing TKR. These findings provide evidence for nurses to incorporate music as an adjunctive approach to enhance the patient's experience and improve outcomes.

Increasing teachers' confidence during health emergencies: A hands-on quality improvement program led by the school nurse.

INTRODUCTION: One in four school-age children has a chronic health condition, with approximately 6% of them having multiple chronic health conditions. These students are at an elevated risk of individual health emergencies during school hours. While teachers receive online training to assist in these emergencies, they lack practicing with rescue medications. METHODS: We developed a Quality Improvement (QI) program that had a) a live presentation; b) a hands-on workshop to practice using rescue medications for allergies, asthma, seizures, and diabetes; c) fliers with first-aid guidelines; and d) a web-based reference toolkit. Teachers' confidence and knowledge were measured using the Learning Self-Efficacy Scale and a knowledge questionnaire with a pre- and post-intervention survey. We also assessed their clinical skills using the rescue medications. RESULTS: 129 teachers took part in this QI program. We collected 95 pre- and 81 post-surveys, with 47 matched. We saw statistically significant increases in confidence, as well as in the individual cognitive, affective, and psychomotor domains. Teachers also increased their overall knowledge. Collaterally, other district-wide improvements developed. CONCLUSION: This evidence-based, hands-on QI program provided teachers the opportunity to put into practice clinical skills, increasing their confidence to help students when experiencing an individual health emergency. Furthermore, changes beyond the primary goal of this QI program were implemented, highlighting the lead role of the registered nurse as the public health advocate. IMPLICATION TO PRACTICE: Laypeople benefit from hands-on training to learn clinical skills. This program serves as a basis for improving health emergencies preparedness in schools.

Evaluation of Chronic, Noncancer Pain Management Initiative in a Multidisciplinary Pain Clinic.

BACKGROUND: Chronic pain management is a major challenge for primary care providers (PCPs). PCPs manage many patients with chronic pain and other comorbidities including mental health problems like post-traumatic stress disorder (PTSD) and depression. Chronic pain and opioid problems are a national crisis, particularly among veterans (U.S. Department of Veterans Affairs, 2019). There are many veterans with chronic non-cancer pain who are being treated with opioids. Chronic opioid use has contributed to an epidemic of opioid-related adverse events (VA, 2017). Opioids not only result in poor pain control, but have associated risks such as misuse, overdose, and diversion which may be fatal (Frieden & Houry, 2016). AIMS: The aim of this project was to evaluate chronic non-cancer pain management of veterans using an advanced practice registered nurse (APRN)-led multidisciplinary team approach to incorporate non-opioid and non-pharmacologic modalities to affect self-reported pain and use of prescribed opioids. METHODS: A retrospective quality improvement (QI) project was conducted in the multidisciplinary pain (MDP) clinic. The APRN used a biopsychosocial approach for chronic pain management guided by the Plan, Do, Study, Act (PDSA) cycle framework. Thirty-four patients who were utilizing opioids for pain management were included using convenience sampling from the MDP clinic. The APRN educated and treated patients with non-opioid medications and non-pharmacolog therapies. A 10-point pain scale and morphine equivalent daily dose (MEDD) were utilized pre- and post-intervention to evaluate the MDP clinic. RESULTS: Participants were predominantly male (91.8%), with a mean age of 63.18 ± 15.39 years, and 36.4% of whom were retired. Only 20.6% of the participants reported the use of opioids for <12 months. Low back pain (93%) was the most common pain location. The mean baseline MEDD was 41.04 and the post tapered MEDD was 23.05; this revealed a significant decline in MEDD (p < .0001). A decline was also found between pre- and post-pain scores (ranges 0-8). There was a significant reported decline in pain scores with a baseline of 6.11 to post tapering pain of 3.1 (t = 4.99, df = 28, p < .0001). Participants preferred non-opioid medications 94% and non-pharmacologic therapy 86%, like physical therapy, yoga, and acupuncture. Fifty-one percent of patients were referred for injections and 46% were referred to primary care behavior health, which includes pain school, sleep hygiene classes, and cognitive behavior therapy. CONCLUSIONS: APRNs are in a key position to assess and treat patients based on current evidence while facilitating opioid titration. This initiative highlights that safe tapering of opioids is possible when utilizing a multidisciplinary approach for chronic pain management. Findings support the use of non-pharmacologic and non-opioid therapy for chronic pain management which can result in reduced patient-reported pain. Further research is warranted to examine both pharmacologic (non-opioid) and non-pharmacologic strategies that promote pain management while tapering opioids.

The Importance of Heart Rate in Heart Failure and Reduced Ejection Fraction.

BACKGROUND: Heart failure with reduced ejection fraction (HFrEF) is a progressive, chronic, and burdensome cardiovascular condition. It is associated with limiting symptoms, such as dyspnea and fatigue; a decline in functional capacity; and premature mortality and hospitalization. In heart failure (HF) management, heart rate is commonly assessed yet frequently overlooked as a modifiable risk factor and a predictor of mortality. An elevated heart rate increases myocardial demand and decreases diastolic filling time. Hospitalized patients with HFrEF who have a heart rate greater than 70 beats per minute at discharge were found to have lower survival rates. PURPOSE: The aims of this study were to review the association between heart rate and clinical outcome in patients with HF and discuss the contribution of heart rate to HFrEF pathophysiology. Medications currently used to modulate heart rate in patients with HF are also reviewed. CONCLUSIONS: In patients with HFrEF, an elevated heart rate contributes to HF progression, and it is both a prognostic and modifiable risk factor. Medications such as an evidence-based ß-blockers, digoxin, and ivabradine are recommended for modulation of heart rate in patients with HFrEF. CLINICAL IMPLICATIONS: Nurses play a pivotal role in managing HFrEF and must understand current evidence of the pathophysiology of elevated heart rate, risks, and management strategies. Early recognition of elevated heart rate and application of guideline-directed pharmacologic treatment for patients with HFrEF and an elevated heart rate remains key to improving patient outcomes.

Intensive Care Unit Sleep Promotion Bundle: Impact on Sleep Quality, Delirium, and Other Patient Outcomes.

BACKGROUND: High-quality sleep is important for optimal patient recovery. Sleep deprivation during hospitalization may lead to poor patient outcomes. OBJECTIVE: To examine whether implementation of a sleep promotion bundle in the intensive care unit affects rates of delirium and agitation, restraint use, and length of stay. METHODS: An evidence-based sleep promotion bundle was developed and implemented in 2 intensive care units in a 1025-bed level I trauma teaching hospital. Deidentified data from the electronic health record were obtained for patients hospitalized before and during the intervention. Data included scores on the Confusion Assessment Method for the Intensive Care Unit, Richmond Agitation-Sedation Scale, and Glasgow Coma Scale; restraint use; and hospital and intensive care unit length of stay. RESULTS: A total of 137 patients during the preintervention period and 149 patients during the intervention period were hospitalized in the intensive care units and met inclusion criteria. A 9-percentage-point decrease in the incidence of delirium from before to during the intervention was found, although it was not statistically significant (P = .07). Significant reductions were found in both intensive care unit (P = .04) and hospital (P = .03) length of stay. A significant decrease was found in Richmond Agitation-Sedation Scale high scores for patients requiring mechanical ventilation (P = .03). No significant differences were found in Richmond Agitation-Sedation Scale low scores, Glasgow Coma Scale scores, or restraint use. CONCLUSIONS: Critical care nurses are in an optimal position to implement evidence-based sleep promotion measures. Further research on sleep promotion bundles is needed.

Cardiac Rehabilitation Phase II Outcomes Prior to and During COVID.

BACKGROUND: The COVID pandemic limited access to many Cardiac Rehabilitation (CR) outpatient programs. OBJECTIVE: The study aimed to examine the outcomes of patients in CR Phase II prior and during the pandemic. METHODS: A single-site retrospective review of CR patients during 2019 (pre-COVID) and 2020 (COVID era) was performed. A linear mixed method explored the effect of COVID on 6-minute walk (6MWT), metabolic equivalents (METs), and quality of life (QOL). A generalized linear mixed method was used to explore the effect of COVID and CR on depression (PHQ-9). RESULTS: Two-hundred and twelve patients were included. CR significantly improved 6MWT (b = 331.45, 95% CI: 295.62 ∼ 367.36), METs (b = 1.79, 95% CI: 1.55 ∼ 2.03), and QOL (b = 1.46, 95% CI: 0.81 ∼ 2.12). Significant interaction (P interaction = 0.04) between COVID and pre-post intervention was found for PHQ-9. CONCLUSIONS: During COVID, patients perceived increased depression and poorer QOL. However, all outcomes improved significantly following CR.

The Heart Failure Patient Foundation Position Statement on Research and Patient Involvement.

BACKGROUND: Heart Failure (HF) is a growing global public health problem affecting approximately 64 million people worldwide. OBJECTIVES: The Heart Failure Patient Foundation developed a position statement to advocate for adult patients with HF to be an active participant in research and for HF leaders to integrate patients throughout the research process. METHODS: A review of the literature and best practices was conducted. Based on the evidence, the HF Patient Foundation made recommendations regarding the inclusion of adult patients with HF throughout the research process. RESULTS: Healthcare clinicians, researchers and funding agencies have a role to ensure rigorous quality research is performed and implemented into practice. Inclusion of adult patients with HF throughout the research process can improve the lives of patients and families while advancing HF science. CONCLUSIONS: The HF Patient Foundation strongly advocates that patients with HF be involved in research from inception of the project through dissemination of findings to improve patient outcomes.

Examination of Nursing Staffs' Perceptions of the COVID-19 Vaccine Using the Health Belief Model.

BACKGROUND: The coronavirus (COVID-19) pandemic profoundly impacted patient care across the United States. OBJECTIVE: To examine nursing staffs' perceptions of the COVID-19 vaccine using the Health Belief Model (HBM) as a theoretical framework. METHODS: A cross-sectional, anonymous, web-based survey was completed by practicing nursing staffs throughout the United States. Analyses involved descriptive and comparative statistics. RESULTS: Of the 294 nursing staff who completed surveys, 50% were between 18 and 37 years of age, and 73.1% were registered nurses, with 49.3% employed in a hospital setting. Nursing staff reported their primary reason for vaccination was concern for others (mean: 84.44; SD: 28.26), vaccine prevents spread (mean: 81.85; SD: 28.94), and own health (mean: 79.63; SD: 30.0). Influencing factors that predicted vaccination included age, Wilks' Λ = 0.76, F(32, 919.86) = 2.20, p < .001, η2partial = 0.066, and the vaccine mandate, Wilks' Λ = 0.63, F(8, 249) = 18.61, p < .001, η2partial = 0.374. CONCLUSION: Nursing staffs' perceptions using the HBM as a theoretical framework provided insight into their decisions to receive the COVID-19 vaccine. Further research is warranted to examine nurses' attitudes and factors that influence their decision-making regarding vaccination.

A cross-sectional study of Hispanic and Latina/o/x/e individuals' acute coronary syndrome symptom knowledge, attitudes, and beliefs.

BACKGROUND: Little attention has been placed on language proficiency as a potential variable affecting ACS symptom knowledge, attitudes, and beliefs. OBJECTIVES: To compare the ACS symptom knowledge, attitudes, and beliefs of Hispanic and Latina/o/x/e individuals proficient in English and in those only proficient in Spanish. Secondary aims were to determine if there were differences in ACS symptom knowledge, attitudes, or beliefs based on participants' previous exposure to ACS symptom information and to evaluate instrument characteristics of the new Spanish version of the ACS Response Index. METHODS: This cross-sectional, comparative study included participants (N = 99) from a community-based clinic in Illinois. Knowledge, attitudes, and beliefs related to ACS symptoms were measured using the ACS Response Index. RESULTS: The average participant was 39.8 (SD 15.6) years of age, female (n = 56, 56.6 %), and had a high school education or less (n = 61, 61.6 %). Participants correctly classified a mean 57.5 % (SD 12.8) of symptoms and had mean attitude and belief scores of 12.1 (SD 3.3) and 17.5 (SD 2.9), respectively. There were no significant differences in knowledge, attitudes, and beliefs based on language proficiency. However, there were some statistically significant differences for knowledge and attitude scores based on exposure to ACS symptom information. The ACS Response Index (Spanish Version) also demonstrated favorable internal consistency. CONCLUSIONS: Overall knowledge, attitude, and belief scores were modest in this sample. Higher knowledge and attitude scores were observed for some types of ACS information exposure, supporting the importance of future educational efforts in this population.

Evidence-based practice: collaboration between education and nursing management.

AIM: To examine practicing nurses' attitudes and knowledge of evidence-based practice. BACKGROUND: Health care providers acknowledge that health care decisions should be grounded in current evidence. Limited evidence documents practicing nurses' attitudes and knowledge regarding evidence-based practice. METHODS: A descriptive survey was administered to 286 practicing nurses. Demographics of educational preparation, area of practice, years in practice, age and gender were collected. RESULTS: The largest number of respondents held an associate degree (30.6%) or baccalaureate degree (29.5%). Thirty-seven per cent reported over 15 years experience in nursing. Forty-three percent reported 61-100% of their practice was evidence based. Fifty percent reported an ability to determine the validity of evidence, and 58% rated an ability to apply findings to individual cases positively. Administrative support of evidence-based practice was reported by only 5.5%. CONCLUSIONS: Nurses voiced agreement that their practice was evidence-based; however, they reported only an average ability to retrieve or critically analyse evidence. IMPLICATIONS FOR NURSING MANAGEMENT: The findings support the need for an educational intervention for practicing nurses regarding evidence-based practice. Role modelling and collaboration of nurse managers and educators will promote transition of evidence into clinical practice.

Bundled Approach to Improve Inpatient Stroke Recognition and Time to Treatment.

ABSTRACT: BACKGROUND: Early recognition of inpatient stroke is critical in reducing poor outcomes. A gap in knowledge and recognition of stroke by nursing staff was observed; protocols did not incorporate the Balance, Eyes, Face, Arms, Speech, and Time (BE-FAST) symptom mnemonic, and code stroke documentation was frequently incomplete. PURPOSE: This initiative aimed to improve timely recognition, evidence-based treatment, and nursing documentation of stroke-related symptoms. METHODS: This quality improvement initiative implemented an inpatient nurse-driven code stroke bundle. A pre-post prospective intervention design was implemented over 3 months. Code stroke bundle components included an evidence-based protocol, algorithm, visual aids, and education. Nursing communication and documentation used the BE-FAST mnemonic in a Situation, Background, Assessment, Recommendation format. RESULTS: Nursing stroke knowledge improved 8% (88% vs 96%, P < .001); stroke response times improved 15 minutes (25.9 vs 11 minutes, P = .383), although not significant; the code stroke documentation completion rate was increased 48.1% (0 [0%] vs 13 [48.1%], P < .001); and improved utilization of the BE-FAST tool with Situation, Background, Assessment, Recommendation communication (0 [0%] vs 20 [47.6%], P = < .001) was observed. The code stroke cancelation rate slightly worsened (10 [26.3%] vs 14 [26.9%], P = .949), code stroke notifications for altered mental status improved (15 [39.5%] vs 8 [15.7%], P = .015), and the stroke mimic rate improved (27 [71.1%] vs 35 [67.3%], P = .708). CONCLUSION: Nurses provide hospital patient care continuously and are in a key position to intervene when patients present changes in symptoms. Through education and creating an evidence-based protocol, nurses can impact patient outcomes in early recognition and activation of the code stroke system. Further studies are warranted to refine strategies leading to continued improvement in early stroke identification.

Predictors of acute coronary syndrome symptom knowledge, attitudes, and beliefs in adults without self-reported heart disease.

BACKGROUND: The time of symptom onset to the time an individual decides to seek care is the most significant contributor to total treatment delay. OBJECTIVES: To explore predictors of ACS symptom knowledge, attitudes, and beliefs in adults without diagnosed heart disease. METHODS: We used a cross-sectional, descriptive, and correlational design, employing an online survey including the ACS Response Index and the avoidance subscale of the Coping Strategy Indicator. We leveraged social media platforms and a university email list-serv to enroll participants. Stepwise hierarchical linear regressions were used. RESULTS: We analyzed responses from 981 participants, with a mean age of 35.2 years (SD 16.5) and 75% female. The regression analyses yielded models that explained 14%, 23%, and 25% of the variance for knowledge, beliefs, and attitudes, respectively. Ethnicity, race, exposure to ACS symptom information (in the media or by teaching), and perceived health were the predictors of ACS symptom knowledge, attitudes, and beliefs with the largest effect, though others were statistically significant. CONCLUSIONS: The findings underscore the importance of community education to raise awareness of ACS symptoms while considering social determinants of health. Future research and clinician interventions for ACS symptom knowledge, attitudes and beliefs should be expanded with a focus on ethnicity and gender.

EXPLORATORY AND CONFIRMATORY FACTOR ANALYSIS OF THE ACS-RESPONSE INDEX IN ADULTS WITHOUT DIAGNOSED HEART DISEASE.

Background and Purpose: To report on the psychometric properties of the Acute Coronary Syndrome Response Index in adults without heart disease. Methods: Participants were enrolled online, using social media platforms and an email listserv. The sample of 1,040 was randomly split into two sub-samples for exploratory and confirmatory factor analysis. Results: Exploratory factor analysis yielded a four-factor solution for the knowledge subscale, a one-factor solution for the attitudes subscale, and a two-factor solution for the belief subscale. Subsequent confirmatory factor analysis demonstrated an excellent fit for the attitudes and beliefs subscales and an acceptable fit for the knowledge subscale. Conclusions: The Acute Coronary Syndrome Response Index can be used with individuals without diagnosed heart disease. However, researchers may wish to omit the incorrect items in the original version of this instrument.

Providing best practice in the management of atrial fibrillation in the United States.

BACKGROUND: Atrial fibrillation (AF) is a prevalent arrhythmia. Patients with AF may report a variety of symptoms and often describe compromised quality of life. Atrial fibrillation increases the risk of stroke, heart failure, and all-cause mortality. PURPOSE: The purpose of this review article was to provide an overview of AF management based on current guidelines and new data. CONCLUSIONS: The 2011 American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society guideline update provides diagnostic and management recommendations for the patient with AF based on the current evidence. CLINICAL IMPLICATIONS: Nurses are integral to the care of patients with AF. It is essential for nurses to stay apprised of current guidelines and new evidence so that the assessment, management, and education of the AF patients and their families can be optimized.

Perceived personal risk and vulnerability in recognizing and responding to symptoms of acute coronary syndrome: an integrative review.

BACKGROUND: Simply knowing the common symptoms of acute coronary syndrome (ACS) is not sufficient to ensure prompt care-seeking when these symptoms occur. Factors other than symptom knowledge contribute to prompt care-seeking behaviours and correct symptom attribution to the heart. OBJECTIVES: To explore how perceived personal risk and perceived personal vulnerability towards ACS affect a person's ACS symptom recognition and attribution and also how this perception affects a person's response to ACS symptoms. DESIGN: An integrative review, using Whittemore and Knafl's approach. DATA SOURCES: PubMed, Academic Search Complete, CINAHL Complete, APA PsycINFO, and APA PsycARTICLES. ELIGIBILITY CRITERIA FOR STUDY SELECTION: We included studies that (i) were original human-subjects research or secondary analyses of human-subjects research, (ii) provided information about how perceptions of risk or perceptions of vulnerability towards ACS or heart disease affect symptom recognition, attribution, and/or response to symptoms, and (iii) were published in English. RESULTS: Thirteen articles were included. Studies were conducted in nine different countries and were descriptive or exploratory in nature. The existing evidence suggests that perceived personal risk or vulnerability towards heart disease may promote earlier care-seeking for ACS symptoms and facilitates attribution of symptoms to the heart. CONCLUSION: The designs of the included studies limit causal attribution, and additional prospective and intervention-based research is needed to determine how perceived risk/vulnerability may affect care-seeking and ACS symptom attribution. Increasing perceptions of vulnerability towards heart disease may reduce care seeking delay.

Providers' assignment of NYHA functional class in patients with heart failure: A vignette study.

BACKGROUND: Accuracy of New York Heart Association Functional Classification (NYHA-FC) I-IV assessment is critical to promoting guideline directed care. OBJECTIVE: Examine providers' accuracy when diagnosing NYHA-FC I-IV in patients with heart failure (HF). METHODS: A web-based survey using validated vignettes was conducted with 244 physicians, nurse practitioners (NP), clinical nurse specialists (CNS) and physician assistants (PA) who provide care to patients with HF. RESULTS: Providers comprised of 65% NPs, 19% physicians, 14% CNSs, 2% PAs with an average of 15 years working with HF patients. Accuracy ranged from 36.9% for Class IV to 78.7% for Class I. Increased HF patient volume seen (p=0.024), physician vs. NP/PA/CNS (p=0.021), and typically assigned a HF stage (p<0.001) were associated with increased total correct score accuracy in multivariable modeling. CONCLUSION: It is critical that NYHA-FC is accurately assigned to promote optimal outcomes. Research in the future should focus on improving accuracy in assigning NYHA-FC.

Providers' accuracy in decision-making with assessing NYHA functional class of patients with heart failure after use of a classification guide.

BACKGROUND: Correct assignment of New York Heart Association Functional Classification (NYHA-FC) I-IV is essential in applying guideline directed care. OBJECTIVE: Examine the validity, reliability, and accuracy of HF and primary care (PC) provider's assignment of NYHA-FC using the NYHA-FC Guide. METHODS: Study utilized a cross-sectional, quasi-experimental known-groups design with validated vignettes. Providers (n = 75) used the Guide to assign NYHA-FC. Known-group validity comparisons (HF specialist/Non-HF specialist - PC provider) and interrater reliability were used to evaluate validity and reliability of the NYHA-FC Guide. RESULTS: HF provider's accuracy total mean scores were significantly higher compared to PC (M = 6.0 vs. 5.4, p = 0.020). HF (62%) and PC providers (80%) reported that the Guide assisted them with deciding HF class. CONCLUSION: The NYHA-FC Guide showed promise for facilitating accuracy of assignment. Further research to evaluate the accuracy of using the NYHA-FC Guide compared to the gold standard six minute walk test is warranted.

Nurses' personal perceptions of clinical work adaptation during COVID-19.

BACKGROUND: The clinical work of nurses across the United States was profoundly impacted by the Coronavirus (COVID-19) pandemic. Nurses in both hospital and outpatient settings had to adapt quickly to the continuously changing healthcare environment. OBJECTIVE: To describe nurses' responses to open-ended questions of their clinical work adaption during the COVID-19 pandemic. METHODS: A descriptive, cross-sectional survey with four open-ended questions was completed by practicing HF nurses. Content analysis was used to analyze the written data. RESULTS: The 127 nurses who provided one to four narrative responses, 55.1% were clinical registered nurses and 44.9% were advance practice nurses. Four categories emerged: changing paths exemplifies work challenges, developing technical skills and resources, asking better questions while listening, and showing resilience through new paths to optimize work. CONCLUSION: Understanding perceptions of nurses' adaptions to clinical work made during the pandemic provides insight into the challenges and opportunities for development in the future.

Perceptions of changes in practice patterns and patient care among heart failure nurses during the COVID-19 pandemic.

BACKGROUND: The Coronavirus (COVID-19) had a profound impact on the delivery of care in both hospital and outpatient settings across the United States. Patients with heart failure (HF) and healthcare providers had to abruptly adapt. OBJECTIVE: To describe how the COVID-19 pandemic affected practice patterns of HF nurses. METHODS: Practicing HF nurses completed a cross-sectional, anonymous, web-based survey of perceptions of HF practice. Analyses involved descriptive and comparative statistics. RESULTS: Of 171 nurses who completed surveys, outpatient HF visits decreased and 63.2% added telehealth visits. Despite spending about 29 min educating patients during visits, 27.5% of nurses perceived that the pandemic decreased patients' abilities to provide optimal self-care. Nurses reported decreased ability to collect objective data (62.4%; n = 78), although subjective assessment stayed the same (41.6%; n = 52). CONCLUSION: Nurses' practice patterns provided insight into patient care changes made during COVID-19. Most core components of HF management were retained, but methods of delivery during the pandemic differed.

Flexible diuretic titration in chronic heart failure: where is the evidence?

BACKGROUND: Several sets of heart failure (HF) consensus/guideline statements support the use of a flexible diuretic dosing regimen for HF outpatient management of fluid overload-related signs and symptoms. However, despite the widespread acceptance of such an approach, the evidence supporting the effectiveness of this approach in improving clinical outcomes is unknown. The primary objective of this manuscript was to summarize and review the evidence supporting the use of a flexible diuretic regimen in the management of outpatient heart failure patients. METHODS AND RESULTS: A systematic review was performed, and 9 studies were identified relevant to the question of flexible diuretic titration in the setting of chronic heart failure. Among the 9 studies, 5 were randomized. Three of the randomized trials included flexible diuretic titration as part of a broader multifaceted disease management program, and only 2 were designed to specifically evaluate the sole contribution of flexible diuretic titration. Collectively, data from all of the studies reviewed supported the idea that flexible and individualized diuretic dosing is potentially associated with reduced emergency room visits, reduced rehospitalization, and improved quality of life in HF patients with reduced ejection fraction. CONCLUSIONS: To date, only 2 randomized clinical studies were identified that were designed to determine the effects of a flexible diuretic dosing regimen in outpatient HF patients with reduced ejection fraction. Data are lacking in HF patients with preserved ejection fraction. There is a critical need to test this strategy in well designed prospective randomized clinical trials.