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Safe transitions from hospital to home for elderly cardiac patients : an integrative review Phillips, Jennifer 2019-03

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  SAFE TRANSITIONS FROM HOSPITAL TO HOME FOR ELDERLY CARDIAC PATIENTS: AN INTEGRATIVE REVIEW  By  Jennifer Phillips B.Sc.N., Vancouver Community College, 2012   A SCHOLARLY PRACTICE ADVANCEMENT RESEARCH (SPAR) PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE IN NURSING  in  THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (School of Nursing)   THE UNIVERSITY OF BRITISH COLUMBIA Vancouver   February 2019 © Jennifer Phillips, 2019     ii Abstract Background: Elderly patients who are discharged after invasive cardiac surgery or transcatheter aortic valve replacement/implantation (TAVR/TAVI) are at risk of experiencing problems and complications with their healthcare needs when they transition from hospital to home.  Elderly patients may feel unprepared, overwhelmed, and unsupported with how to manage their care needs.  Thus, it is essential for healthcare providers to be aware of the challenges this age group face and engage in best practices and approaches to help facilitate a safe transition for this vulnerable patient population.  Objective: To explore the current research literature in order to identify evidence-informed approaches and best practices to help support and facilitate safe transitions from hospital to home for elderly patients after elective, invasive cardiac surgery or TAVR/TAVI.   Methods: For this integrative review, three databases, Medline (Ovid), CINAHL, and Web of Science, were searched for literature.  Inclusion criteria of literature were: (1) reported on research studies using quantitative, qualitative, or mixed methods; (2) focused on the elderly; (3) were written in English; (4) were published between January 2014 and December 2018; and (5) addressed one of the three research questions of this integrative review.     Results: 15 articles met inclusion criteria.  Five addressed patient experiences of their transitions, two addressed predictors or risk factors associated with poor transitions, and nine addressed interventions that have been designed to reduce poor transitions and/or readmissions to hospital.  Thirteen studies provided information on how to support and facilitate a safe transition from hospital to home for elderly patients.  Conclusion: There is limited research on this topic and more specifically on this population of patients.  Healthcare professionals need to be more aware of the challenges elderly patients face in their transitions and they require on-going and additional education in how to support them.  Additionally, in order to improve transitions further, organizations may need to be restructured and policies may need to be developed or changed.  Elderly patient transitions are an important issue in healthcare and additional research is necessary in improving care for this vulnerable patient population.      Keywords: Elderly patients, transitions, safe transitions, cardiac surgery, coronary artery bypass graft, transcatheter aortic valve replacement, transcatheter aortic valve implantation.     iii Preface  This Scholarly Practice Advancement Research (SPAR) project is original unpublished work by Jennifer Phillips.  All work in this project was supervised by Dr. Susan Dahinten and Dr. Sandra Lauck during the planning, research, analysis and writing phases.  The culminating project, an integrative review, has been reviewed and approved by the above committee members.      iv Table of Contents Abstract ...................................................................................................................................... ii Preface ...................................................................................................................................... iii Table of Contents ...................................................................................................................... iv List of Tables.............................................................................................................................. v List of Figures ........................................................................................................................... vi Acknowledgements .................................................................................................................. vii Chapter 1: Introduction ............................................................................................................... 1 Problem Statement .............................................................................................................................. 2 Purpose and Research Questions ......................................................................................................... 3 Significance ........................................................................................................................................ 4 Chapter 2: Methods .................................................................................................................... 5 Data Sources and Search Strategy ....................................................................................................... 5 Inclusion and Exclusion Criteria .......................................................................................................... 8 Screening and Study Selection ............................................................................................................ 8 Data Extraction, Evaluation, and Analysis ......................................................................................... 10 Chapter 3: Findings .................................................................................................................. 32 Characteristics of the Selected Studies ............................................................................................... 32 Research Question 1: Patient Experiences of Transitions ................................................................... 32 Research Question 2: Factors Associated with Poor Transitions......................................................... 34 Research Question 3: Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions .. 34 Chapter 4: Discussion and Conclusion ...................................................................................... 38 Discussion of Key Findings ............................................................................................................... 38 Implications for Nursing Practice ...................................................................................................... 39 Implications for Future Research ....................................................................................................... 41 Strengths and Limitations of this Study ............................................................................................. 43 Knowledge Translation: From Evidence to Practice ........................................................................... 43 Conclusion ........................................................................................................................................ 44 References ................................................................................................................................ 46       v List of Tables Table 1. Search Strategy and Number of Hits.............................................................................. 6 Table 2. Description of Selected Studies ................................................................................... 11 Table 3. Study Findings ............................................................................................................ 21      vi  List of Figures Figure 1. Flowchart of Article Selection ..................................................................................... 9      vii Acknowledgements  I would like to express my sincerest appreciation to my advisors, Dr. Susan Dahinten and Dr. Sandra Lauck, who had incredible patience and unwavering support for me through this process of completing my SPAR project.  After enduring countless obstacles and hurdles, both in my personal life and in school, their amount of time and dedication spent encouraging me and helping me complete this, will not be forgotten.  Thank you so very much.  To my school colleagues and close friends, Neda Grant (Khoshnood) and Megan Human.  I am so grateful to have had you as my friends right from the beginning of this journey.  I would not have been able to complete this without you both and without our friendships.  To my mom and dad who were always there cheering me on and supporting me as always through this process and the rest of life’s challenges.  I am blessed to have such loving parents who always show they are proud of me.  Finally, to my husband Luke.  I cannot express enough words to describe how much you have helped me through this and been there, as you are for me always, solid as a rock supporting me through all the ups and downs.  I am so lucky to have you in my life.  Our daughter, that is due to be born in only a few short days, doesn’t know it yet, but she has the most amazing and loving father waiting to meet her.      1 Chapter 1: Introduction The elderly population is highly vulnerable to experiencing problems and complications with their healthcare needs when they transition from hospital to home (Puls, Guerrero, & Andrew, 2014).  Examples of these problems are feeling unprepared to manage their self-care needs and a lack of appropriate follow-up information to help manage their previous and possibly new, healthcare needs (Puls et al., 2014).  These problems may occur because of poor communication or inadequate education from healthcare providers to the patients and/or families.  Elderly patients are more prone to poor health and they can deteriorate further mentally and physically after discharge from the hospital (Laugaland, Aase, & Barach, 2012).  Thus, it is essential for healthcare providers to be aware of the risks faced by the elderly as they transition between hospital and home and engage in best practices that will facilitate a safe transition between settings.  A transition from hospital to home may be considered ‘unsuccessful’ when it results in elderly patients returning to the emergency room, being readmitted to the hospital, or suffering from further medical complications or events.  Human life expectancy is increasing around the world. With the aging population, there has been an increased prevalence of cardiac disease (Wang et al., 2014), and a corresponding need for cardiac surgery or invasive cardiac procedures.  Many elderly patients are electing to have invasive cardiac procedures performed to prolong and improve quality of life. Because of their age, they are at higher risk of experiencing post-operative or post-procedural complications (Wang et al., 2014).  In addition, due to the current trend in healthcare to reduce hospital length of stay (LOS), discharges have become accelerated, placing a larger burden on patients with more complex and complicated discharge instructions (Kornburger, Gibson, Sadwoski, Maletta, & Klingbeil, 2013).  A reduced length of hospital stay for elderly patients raises concerns as there is reduced contact with healthcare providers and, therefore, less opportunity for education pertaining to expected recovery experiences after their procedure and ongoing cardiac disease management (Throndson & Sawatzky, 2009).  Limited discharge information increases the risk of a negative outcome after discharge for elderly patients.  Elderly patients are at further risk due to the presence of multiple comorbidities, slower recovery time, and weaker conditions and deconditioning after illnesses (Watkins, Hall, & Kring, 2012).  Thus, elderly patients who are discharged from hospital after an invasive cardiac surgery or procedure are at increased risk for an unsuccessful transition to home and poorer health outcomes (Watkins et al., 2012).  It is   2 important for healthcare providers to be mindful of these vulnerabilities in the elderly and the effect they may have on their recovery. My interest in patient transitions between hospital and home stems from my work with the transition services team (TST) within Vancouver Coastal Health (VCH) Authority.  I am employed as a registered nurse transition services coordinator and my daily work involves detailed discharge planning tailored for each patient.  I collaborate and liaise with care management leaders and social workers to ensure that every patient has the appropriate discharge plan and community supports in place before they leave hospital.  My job as a coordinator is to anticipate what patients’ care needs will be on their return to home from hospital.  Once these care needs are established, I set up the appropriate community services that will match their care needs.  These services include community nurses, case managers, physiotherapists, occupational therapists, dieticians, speech language pathologists, and care aides.   The TST practice is guided by the VCH community adult and older adult policies and clinical practice guidelines (VCH Connect “Adult and older adult services,” 2017).  However, the guidelines are not specific to the TST, but are more focused around community healthcare professionals’ practice.  Thus, the transition services leadership team is starting to develop precise guidelines and standard operating procedures specific to best practices for the TST.  The aim of the TST is to ensure that community services are in place to help support patients’ transition from acute care (VCH Connect “Adult and older adult services,” 2017).  The intent of these community services is to support and promote patient’s self-care at home and prevent unnecessary future hospitalizations (VCH Connect “Adult and older adult services,” 2017).  The goal is that the TST will work together with care management leaders, social workers, and other healthcare professionals to ensure each patient has a seamless and safe transition from hospital to home.  The TST believes positive patient outcomes and successful, safe transitions occur when patients do not return to hospital for readmissions and do not suffer any health complications that cannot be supported by community healthcare professionals.  Unfortunately, despite being connected with appropriate community services, some patients are still readmitted soon after discharge with medical complications and/or failure to thrive.  Problem Statement  Despite best efforts for appropriate discharge planning from the TST and other healthcare professionals, some elderly patients still experience unsafe transitions from hospital to home.    3 This can occur when patients are not adequately prepared to manage their self-care needs and/or medical conditions at home which, in turn, may delay or impair their recovery, or put them at increased risk for medical complications or poorer quality of life.  Patients are also more likely to be readmitted to the emergency room or hospital because they are not able to manage their medical conditions and/or healthcare needs.  Some of the patients who may experience unsafe transitions are the elderly patients who need a cardiac procedure to treat their cardiac disease.  These patients elect to have these procedures in order to live longer, experience less symptoms, and maintain the best quality of life.  Therefore, not only is a successful cardiac procedure important in treating their disease but so is a safe transition from hospital to home in order to optimize their best chance of recovery and quality of life.  Therefore, given that some elderly patients are experiencing unsafe transitions, failing to thrive at home, and returning to hospital for treatment, it is important to search for more optimal ways of supporting their discharge from hospital to home. More specifically, there is a need to examine the nursing literature with the goal of identifying evidence-informed best practices that may improve discharge planning practice and support safe transitions for cardiac patients after elective, invasive cardiac procedures.  Purpose and Research Questions The aim of this Scholarly Practice Advancement Research (SPAR) project was to identify, review, and synthesize the nursing literature in order to identify evidence-informed approaches and best practices to help support and facilitate safe transitions from hospital to home for elderly patients after elective, invasive cardiac surgery or transcatheter aortic valve replacement/implantation (TAVR/TAVI).  Three general questions guided this review:  1. What are elderly patients’ experiences of transition after elective, invasive cardiac surgery or TAVR/TAVI? 2. What factors increase the risk of poor transition? 3. What interventions have been tested and found effective at reducing poor transition and/or readmission for elderly patients after elective, invasive cardiac surgery or TAVR/TAVI?  For the purpose of this paper, safe transitions are defined as “coordination and continuity of healthcare as patients transfer between different levels of care” with the emphasis on patient   4 care and safety throughout the entire transition from hospital to home (Laugaland et al., 2012, p. 2915).  Elderly patients are defined as being between the age of 60 and 90 years.  Finally, elective, invasive cardiac surgery is defined as coronary artery bypass grafting (CABG) or surgical aortic valve replacement (SAVR).  All cardiac procedures included in this review are used as treatment for cardiovascular disease (Veronovici, Lasiuk, Rempel, & Norris, 2014).  More specifically, CABG is performed and has become the leading treatment for coronary artery disease (Alkan, Topal, Hanedan & Mataraci, 2017).  Whereas SAVR and TAVR/TAVI are performed for treatment of the most common heart valve disease known as aortic stenosis (McCalmont, 2014).   Significance The knowledge gained from this SPAR may help the TST within VCH to develop best practice guidelines to better support patients in their transition between hospital and home.  It will also be beneficial to share the findings with the other healthcare professionals who work closely with the TST. For example, there is often significant overlap between the TST, care management leaders, and social workers’ roles.  Therefore, the results from this SPAR are relevant and applicable to their practice also and could help enlighten and enrich their work in facilitating safe transitions.  Finally, the results may also be useful to the larger nursing community, to those who have responsibilities for supporting elderly patients’ transition home from hospital.     5 Chapter 2: Methods An integrative review was conducted to identify and summarize current literature on evidence-informed approaches and best practices that facilitate safe transitions from hospital to home for elderly patients after elective, invasive cardiac surgery or TAVR/TAVI.  An integrative review is a type of literature review that systematically searches for literature and synthesizes findings from varied research methodologies in order to understand a particular topic (Whittemore & Knafl, 2005).  This approach was appropriate for this healthcare topic as these types of reviews provide a comprehensive understanding of the problem or issue (Whittemore & Knafl, 2005) and are useful in potentially helping build nursing science and help inform research, practice and policies (“Systematic Reviews,” 2018).  This review was guided by the Whittemore and Knafl integrative review framework; however, data evaluation was limited to an informal assessment of the study design strengths and weaknesses.  Data Sources and Search Strategy A comprehensive search with a focus on elderly patients’ transitions from hospital to home after elective, invasive cardiac surgery or TAVR/TAVI was employed.  Three major medical databases were searched for literature from 2014 to 2018: Medline (Ovid), CINAHL, and Web of Science.  Additionally, a Google Scholar search was performed to ensure a final thorough review of the literature.   After working with the health sciences librarian, a comprehensive and systematic search strategy using a Boolean and proximity operators combination of keywords and medical subject headings was used.  The keywords included “coronar* OR CABG OR coronary artery bypass graft OR TAVI OR transcatheter aortic valve implantation OR TAVR OR transcatheter aortic valve replacement OR SAVR OR surgical aortic valve replacement” OR “cardi* OR heart” adj “surger* OR surgical OR procedure*” AND “elder* OR senior* OR gerontology* OR geriatric*” adj “patient*” AND “discharg* OR after surgery OR after procedure OR after hospitalization” AND “educat* OR information OR follow up OR follow-up”.  Subject headings included “cardiac surgical procedures OR heart valve prosthesis implantation OR transcatheter aortic valve replacement OR coronary artery bypass” OR “surgery, cardiovascular” OR “cardiac valve annuloplasty” AND “aged” OR “aged, 80 and over” OR “frail elderly” AND “patient discharge” AND “patient education” OR “patient discharge education”.  Table 1 identifies the specific search strategies used for each database and search engine, and number of hits.   6 Table 1. Search Strategy and Number of Hits Source Search Strategy Number of Hits Medline (Ovid) Cardiac surgical procedures/ or heart valve prosthesis implantation/ or transcatheter aortic valve replacement/  OR Coronary Artery Bypass/  OR (coronar* or CABG or coronary artery bypass graft or TAVI or transcatheter aortic valve implantation or TAVR or transcatheter aortic valve replacement or SAVR or surgical aortic valve replacement).ti, ab.  OR ((cardi* or heart*) adj (surger* or surgical or procedure*)).ti, ab.  AND Aged/or “aged, 80 and over”/ or frail elderly/  OR ((elder* or senior* or gerontology* or geriatric*) adj patient*).ti, ab. AND Patient discharge/  OR (discharg* or after surgery or after procedure or after hospitalization).ti, ab.  AND Patient education as Topic/ OR (educat* or information or follow up or follow-up).ti, ab.   Limit  to (English language and yr=”2014-current”)   1035 CINAHL MH “surgery, cardiovascular” or MH “heart valve prosthesis” or MH “cardiac valve annuloplasty”  OR MH “Coronary artery bypass”  OR TI (coronar* or CABG or coronary artery bypass graft or TAVI or transcatheter aortic valve implantation or TAVR or transcatheter aortic valve replacement or SAVR or surgical aortic valve replacement) or AB (coronar* or CABG or coronary artery bypass graft or TAVI or transcatheter aortic valve implantation or TAVR or transcatheter aortic valve replacement or SAVR or surgical aortic valve replacement) OR 225   7 TI (cardi* or heart*) N0 (surger* or surgical or procedure*) or AB (cardi* or heart*) N0 (surger* or surgical or procedure*) (13571) AND MH (“aged OR “aged, 80 and over” or “frail elderly”) OR  TI (elder* or senior or gerontology* or geriatric*) N0 (patient*) or AB (elder* or senior or gerontology* or geriatric*) AND MH (“patient discharge”)  OR TI (discharg* or after surger* or after procedure* or after hospital*) or AB (discharg* or after surger* or after procedure* or after hospital*) AND MH (“patient education” or “patient discharge education”) OR TI (educat* or information or follow up or follow-up) or AB (educat* or information or follow up or follow-up)  Limit to year 20140101-20181231, English language  Web of Science TS=((cardi* OR heart*) NEAR/0 (surger* OR surgical OR procedure*)) OR TS=(coronar* OR CABG OR “coronary artery bypass graft” OR TAVI OR “transcatheter aortic valve implantation” OR “surgical aortic valve replacement” AND  TS=((elder* OR senior* OR gerontolog* OR geriatric*) NEAR/0 (patient*)) AND TS=(educat* OR information OR “follow* up”) AND TS=(discharge* OR “after surger*” OR “after procedure” OR “after hospital*”)  106 Total 1366      8 Inclusion and Exclusion Criteria Articles were included if they: (1) reported on research studies using quantitative, qualitative, or mixed methods; (2) focused on the elderly; (3) were written in English; (4) were published between January 2014 and December 2018; and (5) addressed one of the three research questions of this integrative review.  Studies were included as long as 50% or more of data was reported exclusively on either elective cardiac surgery (CABG or SAVR) or TAVR or TAVI.  Studies were excluded if they were non-research articles or systematic reviews.  Other exclusion criteria included literature that focused more than 50% of their data on transitions from an acute care setting to an intensive care setting or cardiac rehabilitation center or long term care facility.  Additionally, studies that addressed mitral valve, tricuspid valve, and/or pulmonary valve surgery were excluded along with any studies that did not measure outcomes within three months after discharge from the hospital.   Screening and Study Selection The search strategies yielded a total of 1366 articles: 1035 articles from Medline (Ovid), 225 from CINAHL, and 106 from Web of Science. After removing duplicate citations n=78, the remaining 1288 articles were screened based on their titles and abstracts to ensure relevance to the three research questions, and another 1230 citations were removed. The full text of each of the remaining 58 articles was then screened using the inclusion/exclusion criteria yielding a final sample of n=10 articles. An ancestry search and Google Scholar search was also performed to identify a further n=5 appropriate sources. A total of 15 articles were included in this project.  A PRISMA flowchart of the article selection is included (see Figure 1).      9                        Figure 1. Flowchart of Article Selection          Medline (Ovid) n=1035 CINAHL n=225 Web of Science n=106 Total n= 1366 Literature included in integrative review n=15 Full text literature assessed n=58 Exclusions based on full text assessments n=48 • Study procedure as per inclusion criteria was performed less than 50%  • Study addressing transition to location other than home more than 50%  • Study outcomes were >3 months  Unique citations from databases n=1288 Duplicate citations removed n=78  Excluded titles and abstracts that did not adhere to inclusion criteria n=1230   Additional records found through other sources:  Ancestry search n=1 Google Scholar n=4  Final sample n=10   10 Data Extraction, Evaluation, and Analysis Information describing the characteristics of each of the 15 included studies was extracted and recorded in a Word table. These data include: author, publication year and title, purpose, research study design, sample and setting, cardiac procedure, data collection, and data analysis (see Table 2).  Table 2 also identifies each study’s strengths and limitations, based on design and methods of data collection and analysis.  The findings of each study were also extracted and recorded in a Word table (see Table 3), categorized according to the three research questions: patient experiences of transitions, factors associated with poor transitions, and tested interventions to reduce poor transitions and/or readmissions.  Also included in Table 3 was a category for authors’ recommendations for safe transitions.  The tables allowed for comparing and summarizing of data across all pieces of literature (Garrard, 2014).     11 Table 2. Description of Selected Studies  Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations 1 – Ad, Holmes, Halpin, Shuman, Miller & Lamont (2016)  The effects of frailty in patients undergoing elective cardiac surgery To assess if frailty had any impact or effect on patient outcomes after surgery.  Observational, Cohort  Prospective N= 166  Mean (SD) age: 74 (6.6) years  Setting: One institution in Virginia, USA  Elective cardiac surgery: CABG and/or Valve  Measures:  LOS in ICU and hospital, discharge to care facility, complications, readmissions (up to 30 days) and mortality (within one year).  Logistic regression  Strengths:  - One year follow-up - Many control variables used   Limitations: - Few patients were identified as being frail  2 –  Al-Daakak, Ammouri, Isac, Gharaibeh & Al-Zaru (2016)  Symptom management strategies of Jordanian patients To identify symptoms experienced by patients after CABG and the symptom management strategies used to relieve these symptoms.  Descriptive Cross-sectional  N= 100  Mean age: 57.7 years  Setting: 5 hospitals in Amman, Jordan First time CABG Measures: Cardiac Symptom Survey and questionnaire of categories of symptom management strategies administered by telephone two weeks post-operatively.  Descriptive statistics Chi square Strengths: - Sample from five hospitals  Limitations:  - Only one follow-up data collection point at two weeks - Convenience sampling - Cannot infer causal   12 Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations following coronary artery bypass grafting surgery relationships   3 –  Ammouri, Al-Daakak, Isac, Gharaibeh & Al-Zaru (2016)  Symptoms experienced by Jordanian men and women after coronary artery bypass graft surgery To assess for symptoms experienced by patients after CABG and if any demographic variables are associated with the symptoms experienced.  Descriptive Cross-sectional  N= 100   Mean age: 57.7 years   Setting: 5 hospitals in Amman, Jordan First time CABG Measures: Cardiac Symptom Survey  administered by telephone two weeks post-operatively.  Descriptive statistics Chi square Strengths: - Sample from five hospitals  Limitations:  - Only one follow-up data collection point at two weeks - Convenience sampling - Cannot infer causal relationships 4 – Bikmoradi, Masmouei, Ghomeisi & Roshanaei (2015)  Impact of tele-nursing To assess the impact of tele-health nursing on patients' adherence to the discharge treatment plan after CABG. Quasi-Experimental  N= 71 patients (35 control & 36 intervention)  Mean (SD) age: 64 (7.7) years in control group. CABG  Measures: Adherence to treatment plans questionnaire administered the day before discharge and collected again ANCOVA Strengths: - Controlled for baseline  Limitations: - Small convenience sample - One site   13 Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations on adherence to treatment plan in discharged patients after coronary artery bypass graft surgery: A quasi-experimental study in Iran 62 (7.4) years in intervention group.   Setting: One institution in  Hamadan, Iran at five weeks post-discharge. 5 –  Bikmoradi, Masmouei, Ghomeisi, Roshanaei & Masiello (2017)  Impact of telephone counseling on the quality of life of patients discharged after coronary artery bypass grafts  To assess the impact of telephone education and counseling on the quality of life of patients after CABG.  Quasi-Experimental   N= 71 (35 control & 36 intervention)  Mean (SD) age: 64 (7.7) years in control group. 62 (7.4) years in intervention group.   Setting: One hospital in Hamadan, Iran CABG Measures: MacNew Heart Disease Health-Related Quality of Life Questionnaire administered before discharge and again at five weeks post-discharge. Bivariate statistics Limitations:  - No multivariate statistics  - Small convenience sample  - One site  - No control for baseline QOL    14 Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations 6 –  Bjornnes, Parry, Lie, Fagerland, Watt-Watson, Rustoen, Stubhaug & Leegaard (2017)  The impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery To examine the impact of a pain management booklet on patients' pain characteristics, their use of analgesics, and pain control after cardiac surgery.  Randomized controlled trial  N= 349 (175 control & 174 intervention)  Mean (SD) age: 66 (10) years  Setting: Two cardiothoracic surgical units at a regional hospital in Oslo, Norway Elective cardiac surgery: CABG and/or Valve  Measures:  Self-Administered Comorbidity Questionnaire administered at baseline.  Brief Pain Inventory - Short Form questionnaire plus self-reported analgesic intake questionnaire completed at 2 weeks post-discharge and again at 1, 3, 6, and 12 months post-discharge.  General linear mixed models Strengths: - RCT - Large sample size - Multiple follow-up data collection points  - Patients were blinded to control or intervention group   Limitations: - Single site  7 – Hall, Esposito, Pekmezaris, Lesser, Moravick, Jahn, Blenderman, Akerman To assess the impact of nurse practitioner home follow-up visits after CABG on readmission Observational, Cohort Retrospective N= 401 (232 control & 169 intervention)  Mean age: 64 years  CABG Measures: Readmission and mortality rates (within 30 days), from the New York Cardiac Surgery Reporting System and The Logistic regression  Strengths: - Large sample size  Limitations: - Single site     15 Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations Nouryan & Hartman (2014)   Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions rates and death.  Setting: One center in metropolitan New York Society of Thoracic Surgeons databases.   8 –  Hweidi, Gharaibeh, Al-Obeisat, Al-Smadi (2018)  Prevalence of depression and its associated factors in patients post-coronary artery bypass graft surgery To identify depression levels in patients post-CABG and if depression levels are affected by patient characteristics.    Descriptive correlational Cross-sectional  N= 143  Mean age: 64.1 years  Setting: Three major referral hospitals in two cities in Jordan.  First time CABG Measures:  Self-rating Depression Scale during hospitalization.     Step-wise multiple regression  Strengths: - Sample from three hospitals  Limitations:  - Convenience sampling - Data collection in hospital only and no follow-up after discharge   16 Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations 9 –  Lapum, Fredericks, Liu, Yau, Retta, Jones & Hume (2016)   Facilitators and barriers of heart surgery discharge: Patients' and nurses' narrative accounts To explore patients' and nurses' personal experiences of barriers and facilitators towards discharge after CABG.  Qualitative narrative methodology   N= 10 patients, 7 nurses  Age range patients: 37-80 years.  Age range nurses: 24-54 years.   Setting: One hospital in Ontario, Canada CABG and/or valve repair or replacement Measures:  For patients, individual interviews were conducted in their homes at one week after discharge and again at four to six weeks post-discharge.  Nurse interviews were held once in a private room in hospital after patients were discharged.   Narrative analysis  Strengths: - Two perspectives of experiences from patients and nurses - Patients were interviewed at two different times  Limitations: - Only one site for sample  10 –  Li-Wei, Shu-Hua, Chien-Sung, Yue-Cune & Chi-Wen (2016)  Multimedia exercise training program improves distance To examine a multimedia exercise training program and the potential effect it has on patients post-operatively and after discharge Quasi-Experimental Longitudinal N= 60 patients (40 control & 20 intervention)  Mean (SD) age: 61.3 (13.4) years  Setting: University-affiliated teaching First time CABG and/or valve repair or replacement Measures: six-minute walking test, heart rate recovery and Self-efficacy Scale data measured at baseline before surgery, then one to two days before discharge, and then one Generalized estimating equation  Strengths: - Objective performance measures - Longitudinal  Limitations: - Follow-up time is within one month - Small sample - One site    17 Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations walked, heart rate recovery, and self-efficacy in cardiac surgery patients from the hospital.  hospital in northern Taiwan month post-discharge. 11 –  Özen & Sevig (2017)  The impact of planned hospital discharge program on complications and hospital readmissions in patients undergoing coronary artery bypass grafting To determine if a discharge training program impacts post-operative management of care, complications, and/or hospital readmissions after CABG.  Randomized controlled trial  N= 48 patients (24 control & 24 intervention)  Mean (SD) age: 63.8 (7.7) years in control group.  59.7 (7.9) years in intervention group.   Setting: Cardiovascular surgery service (CVS) and CVS intensive care unit of a hospital in Turkey.  CABG  Measures:  Home Visit Control Form administered at the home visit at 25-30 days post-discharge.     Bivariate statistics Strengths: - RCT - Patients were blinded   Limitations:  - Small sample size - One site - No multivariate statistics used   18 Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations 12 –  Subeh, Salami & Saleh (2014)  Most frequent and severe symptoms and learning needs among CABG patients  To determine the severity and frequency of patient symptoms along with the most frequent learning needs after discharge from CABG.  Descriptive Cross-sectional  N= 161  Mean (SD) age: 55.1 (7.9) years  Setting: One large teaching hospital and one large military hospital in Amman, Jordan  First time, elective CABG  Measures:  Self-reported questionnaires: Cardiac Symptom Survey, Cardiac Patients Learning Needs Inventory, and demographic factors collected at an outpatient clinic appointment within the first month post-discharge.  Descriptive statistics Strengths: - Large sample size  Limitations:  - Convenience sample from two hospitals - One month follow-up only - No specific identified collection time for questionnaire reports 13 –  Varaei, Shamsizadeh, Cheraghi, Talebi, Dehghani & Abbasi (2014)   Effects of a peer education on cardiac self-efficacy and To determine the effect of peer education on cardiac self-efficacy and readmission rates for patients after CABG. Randomized controlled trial N= 60 patients (30 control & 30  intervention)  Mean (SD) age: 60.7 (8) years in control group.  58.9 (8.3) years in intervention group.   First time CABG Measures: Cardiac Self-Efficacy Scale measured at five days, four weeks, and eight months after discharge.  Readmission rates (measured up to eight months).  Repeated measures ANOVA and chi square  Strengths:  - RCT  - Long follow-up - 2 sites for sample   Limitations:  - Small sample size   19 Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations readmissions in patients undergoing coronary artery bypass graft surgery: a randomized-controlled trial Setting: Two hospitals in urban area in Iran  14 –  Wong, Montoya & Quinlan (2018)  Transitional care post TAVI: A pilot initiative focused on bridging gaps and improving outcomes To identify the impact of targeted discharge education strategies and two telephone follow-up calls on patients’  transition after TAVI and if this intervention reduces hospital readmissions.  Also looks to identify potential risk factors for Pilot Study Descriptive   N= 77   Mean age: 81.6 years  Setting: Tertiary centre in Canada  TAVI Measures: Structured interview tool administered over telephone at three days and thirty days after discharge.  Descriptive statistics Limitations:  - Small sample  - Single site   20 Author, (Year), and Title Purpose Research Study Design Sample and Setting Cardiac Procedure Data  Collection Data Analysis Strengths and Limitations poor transition.  15 –  Yildiz, Gürkan, Gür, Ünsal, Göktas & Özen (2014)  Effect of standard versus patient-targeted in-patient education on patients' anxiety about self-care after discharge from cardiovascular surgery clinics To identify if the use of in-patient individualized education effects patients' anxiety around self-care after discharge from CABG.  Randomized controlled trial Prospective N= 198  (98 control & 100 intervention)  Mean (SD) age: 62.1 (10.2) years in control group. 59.1 (9.8) years in intervention group  Setting: Cardiovascular surgery clinic within a hospital in Turkey  CABG Measures:  Patient learning needs scale administered to intervention group before  education.  State-trait anxiety inventory measured before  education/teaching and at discharge while in hospital.   Bivariate statistics Strengths:  - RCT - Large sample - Prospective  Limitations:  - Bivariate statistics only - Data collection in hospital only and no follow-up after discharge - Didn't evaluate other health outcomes - Single site   21 Table 3. Study Findings   Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions 1 – Ad, Holmes, Halpin, Shuman, Miller & Lamont (2016)  The effects of frailty in patients undergoing elective cardiac surgery   Higher frailty scores were associated with longer ICU stays, longer total LOS, increased  complications and increase in discharges to intermediate care facilities.  However, frailty was not associated with major outcomes such as mortality or readmissions.    No recommendations were indicated other than a further need for alternative measures to assess frailty in the pre-operative period for cardiac surgery patients.  2 –  Al-Daakak, Ammouri, Isac, Gharaibeh & Al-Zaru (2016)  Symptom management strategies of Jordanian patients following coronary artery Symptom of chest incisional pain and leg swelling was managed with medications and repositioning. Symptom of poor appetite was managed with changing diet.  Symptom of difficulty in sleeping was managed with medications, distraction, and altering routines.  Symptom of fatigue was     Providing information to patients about symptoms following CABG will provide a better understanding of how they can self-manage and cope after discharge. Providing education about coping strategies for managing symptoms, provides patients the ability to recall how to initiate and practice these strategies consistently, or   22 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions bypass grafting surgery managed with rest.  Symptom of anxiety was managed with distraction.    Symptom management strategies for symptoms of poor appetite, sleeping problems and fatigue that were used were associated with demographic variables gender, age and chronic disease.  seek out help if symptoms arise.    Additionally, addressing common symptoms experienced and associated management strategies is recommended as this may help prevent readmissions and improve quality of life for patients post CABG.  3 –  Ammouri, Al-Daakak, Isac, Gharaibeh & Al-Zaru (2016)  Symptoms experienced by Jordanian men and women after coronary artery bypass graft surgery Most frequently perceived symptoms experienced included chest incisional pain, leg swelling, poor appetite, trouble sleeping, and leg incisional pain. Followed by fatigue, anxiety, SOB, fluttering, angina and depression.  Poor appetite, sleeping problems, and fatigue were associated with demographic variables such as age, gender,     The findings from this study should be used to help prioritize healthcare learning and education for patients post-CABG and to consider symptoms that may be experienced due to cultural and social differences between patients.     23 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions history of chronic disease, and knowing somebody in the health field.   4 – Bikmoradi, Masmouei, Ghomeisi & Roshanaei (2015)  Impact of tele-nursing on adherence to treatment plan in discharged patients after coronary artery bypass graft surgery: A quasi-experimental study in Iran     Intervention: Tele-nursing follow-up calls   The intervention resulted in patients having increased adherence to their treatment plan.  It also increased adherence to diet, physical activity and exercise, and spirometry use recommended after CABG.   No significant difference for adherence to medication plan between groups.   Tele-nursing is encouraged as a way to respond to patients' questions and provide additional education, training, and counseling after CABG.  It is an intervention that may help patients adhere to their discharge treatment plan and help improve patients' quality of life.    24 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions 5 –  Bikmoradi, Masmouei, Ghomeisi, Roshanaei & Masiello (2017)  Impact of telephone counseling on the quality of life of patients discharged after coronary artery bypass grafts     Intervention: Telephone counseling follow-up calls   Quality of life scores (physical, social, emotional domains, and total score) improved after intervention.   Telephone counseling should be considered as a way for healthcare professionals to educate, consult, follow-up, and answer questions of CABG patients and of their families after discharge as it promotes an improved/higher quality of life.  6 –  Bjornnes, Parry, Lie, Fagerland, Watt-Watson, Rustoen, Stubhaug & Leegaard (2017)  The impact of an educational pain management booklet intervention on     Intervention: Educational pain management booklet   Intervention group showed no significant results in improvement in pain control or pain ratings.   Patients from both groups reported inadequate pain control post-operatively up to a year post-There is a need for better post-operative pain management education for patients due to patients experiencing pain up to a year post-operatively and having concerns in managing their pain.     25 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions postoperative pain control after cardiac surgery discharge.  In addition, patients indicated concern about managing their pain and their pain medications. 7 – Hall, Esposito, Pekmezaris, Lesser, Moravick, Jahn, Blenderman, Akerman Nouryan & Hartman (2014)   Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions     Intervention: Two home visits by cardiac surgery hospital nurse practitioner (NP) within first week to 10 days after discharge   Intervention group showed significantly lower rates of  readmission and death within 30 days.  Results indicated the benefit of NP home visits and their management of patient care.  NP home visits are useful after discharge following CABG as it improves continuity of care across healthcare settings and delayed unnecessary readmissions along with reducing mortality rates.  8 –  Hweidi, Gharaibeh, Al-Obeisat, Al-Smadi (2018)  Findings indicated that patients after CABG experience a moderate level of depression. Higher levels of depression were found in     Improved discharge planning and more effective discharge teaching/education for patients is recommended so as to help reduce any   26 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions Prevalence of depression and its associated factors in patients post-coronary artery bypass graft surgery patients who were unemployed, who received education from their physicians versus nurses, had higher levels of education, and patients who received care in public hospitals versus private or university affiliated hospitals for their CABG.  Age, length of stay in the CICU, and hospital type were found to be predictors of depression.   psychological impact (i.e., depression) that may be experienced after CABG.    Implementing a new discharge plan and providing more education to patients will allow for increased personal patient awareness on how to successfully cope and adapt after CABG in the hope to mitigate depression.   9 –  Lapum, Fredericks, Liu, Yau, Retta, Jones & Hume (2016)   Facilitators and barriers of heart surgery discharge: Patients' and nurses' narrative accounts Facilitators identified in the discharge process were: fostering therapeutic relationships between nurses and patients, tailoring discharge education specifically to each patient, and providing opportunity for patients to interact and communicate with healthcare professionals.  Barriers to     Effective communication techniques, time for dialogue with patients, and individualizing the approach of discharge education and counselling are recommended.   Education and support should be provided as early as the pre-operative period and at a time when patients are in their best   27 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions an effective discharge were: heavy workload, shorter hospital length of stay, and insufficient time for healthcare professionals. Altered cognitive status in the post-operative period was also a barrier to receiving discharge education.  cognitive state.  Furthermore, creative strategies such as use of volunteers or peer support groups and telephone follow-up calls would be beneficial in the early recovery period and help facilitate the transition home.  10 –  Li-Wei, Shu-Hua, Chien-Sung, Yue-Cune & Chi-Wen (2016)  Multimedia exercise training program improves distance walked, heart rate recovery, and self-efficacy in cardiac surgery patients     Intervention: Individually tailored exercise training and multimedia DVDs and printed booklets   The intervention group showed improvements in distance walked in the six-minute walking test, heart rate recovery and self-efficacy at discharge and again at one month after discharge.  Continuing this type of exercise training program for patients after cardiac surgery is encouraged as it indicates patients are more adequately prepared for discharge and could help in transitioning from inpatient cardiac rehabilitation to outpatient.    28 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions 11 –  Özen & Sevig (2017)  The impact of planned hospital discharge program on complications and hospital readmissions in patients undergoing coronary artery bypass grafting     Intervention: Discharge training program that involved discharge education provided 2-3 times per day from admission to discharge, an education booklet and access to healthcare professionals via phone while in hospital and after discharge.   Intervention group found patients had increased control over systolic blood pressure, increased adherence to training rules regarding nutrition, constipation management and exercise, and patients quit smoking.  Additionally, there were decreased complications and decreased hospital readmissions.  Including a discharge training program for patients after CABG is recommended as it improves the post-operative management of care, decreases complications, and reduces hospital readmissions.  12 –  Subeh, Salami & Saleh (2014) The most severe and frequent symptoms that were identified were chest     Including information and support for these specific symptoms and including a   29 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions  Most frequent and severe symptoms and learning needs among CABG patients incision/leg pain, anxiety and sleep disturbances.    The most frequent learning needs were wound care, complication information, and psychological factors.  follow-up at least one month after surgery is recommended in order to promote health and address patients' learning needs.   13 –  Varaei, Shamsizadeh, Cheraghi, Talebi, Dehghani & Abbasi (2014)   Effects of a peer education on cardiac self-efficacy and readmissions in patients undergoing coronary artery bypass graft surgery: a randomized-controlled trial     Intervention: Peer education   Intervention group resulted in higher cardiac self-efficacy and lower   readmission rates after 8 months.      Incorporating peer education into discharge education for patients undergoing CABG is recommended, as well as using the results of this study as a benchmark for further development of peer education programs.    30 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions 14 –  Wong, Montoya & Quinlan (2018)  Transitional care post TAVI: A pilot initiative focused on bridging gaps and improving outcomes   Medication non-compliance, poor fluid management, and experiences of anxiety and depression were all identified as risk factors that could lead to poor transitions for patients.  Intervention: Targeted discharge education strategy delivered by an advanced practice nurse prior to discharge and two follow-up telephone calls at three and 30 days post-discharge.   This study found that when providing the intervention, there is an opportunity for healthcare providers to intervene and support patients as needed.  This ensures safe transitional care and continuity of care for patients.  Readmission rates were also slightly lower with this intervention.  A tailored discharge approach to follow-up with patients after TAVI is encouraged as it provides an opportunity for healthcare providers to provide interventions or support to ensure a safe transition to home.  The discharge approach would be recommended to start early while patients were in hospital and to ensure the appropriate follow-up in the community was provided.  15 –  Yildiz, Gürkan, Gür, Ünsal, Göktas & Özen (2014)      Intervention: Daily individualized education provided while patients were in hospital.  Education was based off In-patient education about patients' home care needs and new lifestyle expectations to patients is recommended in order to decrease patients' anxiety   31 Author, (Year), and Title Research Question 1: Patient Experiences of Transitions Research Question 2: Factors Associated with  Poor Transitions Research Question 3:  Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions Authors' Recommendations for Safe Transitions Effect of standard versus patient-targeted in-patient education on patients' anxiety about self-care after discharge from cardiovascular surgery clinics of patients’ learning needs.   In-patient education was found to be effective in reducing patients' anxiety while being in hospital after CABG.  Additionally, in-patient education that was specific and individualized to patients' learning needs was more effective than standard education in reducing anxiety about self-care after discharge.  after CABG.  Additionally, the information should be individualized as it further reduces anxiety for patients as they transition from hospital to home.    32 Chapter 3: Findings Fifteen studies were reviewed for the purpose of identifying evidence-informed approaches and best practices to help support and facilitate safe transitions from hospital to home for elderly patients after elective, invasive cardiac surgery or TAVR/TAVI. Characteristics of the Selected Studies The characteristics of the studies included in this review are summarized in Table 2. The 15 studies were published between January 2014 and December 2018.  Four studies were published in 2014, one in 2015, five in 2016, three in 2017, and two in 2018. The studies were conducted in seven countries: Jordan (n=4), Iran (n=3), Turkey (n=2), the United States (n=2), Canada (n=2), Norway (n=1), and Taiwan (n=1). There were a range of study designs with four being randomized controlled trials (RCTs), three quasi-experimental, four descriptive, one descriptive correlational, two observational cohort, and one qualitative descriptive study.  Sample sizes ranged from 48 to 401 participants for the 14 quantitative studies, with 17 participants in the qualitative study. Participant ages also varied. The mean age for each study ranged from 55 to 82 years. However, most study samples had a mean age of 65 years. Only three studies had a mean sample age greater than 65 years and only one of these had a mean age greater than 80 years (M=82).  Of the 15 studies in this review, five addressed patient experiences of their transitions (research question 1), two addressed predictors or risk factors associated with poor transitions (research question 2), and nine addressed interventions that have been designed to reduce poor transitions and/or readmissions to hospital (research question 3). One study addressed both risk factors and interventions to reduce poor transitions and readmissions. Further details about study methods and study quality are included in the following sections on findings of the studies related to each research question.  Research Question 1: Patient Experiences of Transitions  Patients’ experiences of their transition were investigated in studies 2, 3, 8, 9, and 12.  Four of these five studies used non-experimental quantitative methods while one used qualitative methods with narrative analysis (study 9).  Studies 2 and 3 were based on the same dataset but answered different questions. Four of the studies (studies 2, 3, 8, and 12) were conducted in Jordan by different research groups, performed at multiple sites, and focused on patients who were experiencing their first elective CABG.  In contrast, study 9 was conducted in Canada, at   33 only one site, and the sample included patients with CABG and/or cardiac valve repair/replacement. Data collection methods and timing also varied across these studies with follow-up data being collected between one and six weeks post-discharge. Data collection methods included the use of a self-rating scale administered while the patient was in hospital (study 8) or attending outpatient clinic follow-up appointments (study 12), telephone-administered surveys (studies 2 and 3), and home-based patient interviews (study 9). Study 2, 3 and 12 were similar in that their aim was to identify symptoms experienced after first time CABG.  Study 2 and 3 used the same database so the results are identical for the ranking of most frequently perceived symptoms. Study 2, 3 and 12 all ranked chest incisional pain as the most frequently experienced symptom followed by leg pain/swelling. Study 12 found that anxiety and sleep disturbances were the next most frequently reported symptoms, whereas study 2 and 3 reported poor appetite, followed by anxiety and sleep disturbance as the next most common symptoms. The least frequently reported symptoms in all three studies were heart fluttering (tachy arrhythmias), depression, and angina. The similarities in findings may be at least partially related to the common research setting (i.e., Jordan), the common use of the Cardiac Symptom Survey, and similar follow-up periods following the same procedure (first time CABG).    In addition to identifying post-CABG symptoms, study 2 investigated symptom management strategies and study 12 discussed most frequent learning needs reported by patients. Study 2 found the most commonly used strategies for reducing symptoms experienced after CABG were: medication management, rest or repositioning, seeking out help, changing diets, distraction and altering sleep routines. Study 12 found the most common learning needs reported by patients was information about wound care, complications, and psychological factors including anxiety and depression.    Study 8, also conducted at multiple sites in Jordan, focused solely on patient experiences of depression post-CABG.  In contrast to the findings of studies 2, 3, and 12 which identified depression as one of the least common symptoms experienced after CABG, study 8 found that patients experienced moderate levels of depression, with very few patients reporting no depression experienced at all after CABG.  This difference in findings may be due to depression being assessed while patients were still in hospital for study 8, whereas, the other three studies assessed depression within the first month after discharge.        34 Study 9 investigated patient and nurse experiences of the discharge process with a focus on the facilitators and barriers of a successful transition after discharge. Study 9 found that adequate time to develop a therapeutic nurse-patient relationship facilitated the discharge process. Inadequate time, attributed to shorter hospital stays for patients and heavier workload for nurses, acted as a barrier to effective discharge. Another factor identified by patients as a facilitator of the discharge process and successful transition was having additional support at home.  Furthermore, both patients and nurses identified the importance of tailoring discharge information to each patients’ home situation, to facilitate recovery and discharge. Finally, patients reported that their altered cognitive and emotional states at time of discharge was a barrier to an effective discharge as they negatively impacted their knowledge retention and, consequently, their ability to apply discharge information once they were at home.   Research Question 2: Factors Associated with Poor Transitions  Two studies, study 1 and 14, investigated predictors or risks of a poor transition.  Study 1, conducted in the United States with 166 cardiac surgery patients (either CABG or valve surgery), focused on frailty and found that higher levels of frailty were associated with more complications, longer LOS in an intensive care unit, longer overall LOS in hospital, and increased odds of being discharged to an intermediate-care facility rather than home. However, frailty was not associated with readmissions after 30 days post-discharge or mortality after one year post-discharge.  This study did not investigate whether the increase in complications or longer LOS negatively impacted their transition from hospital to home. Study 14, conducted in Canada with 77 TAVI patients, focused on transition issues such as medication management, follow-up appointments, symptoms, physical activity, quality of life, and mental health.  Findings indicated that patients are at risk of a poor transition when medication non-compliance, unsuccessful fluid management (diet, daily weights, recording blood pressure, and self-care management), and incidences of anxiety and depression occur after discharge. Research Question 3: Evaluation of Interventions to Reduce Poor Transitions and/or Readmissions   Nine studies addressed interventions to reduce poor transitions and/or readmissions.  Three studies examined the effect of telephone follow-up calls (study 4, 5, 14); one study examined the effect of follow-up home visits (study 7), and five assessed various forms of specialized education for patients prior to discharge (Study 6, 10, 11, 13, and 15). Seven of the   35 studies used experimental designs; studies 7 and 14 used non-experimental designs. The studies were conducted in six different countries, with sample sizes ranging from 48 to 401 patients. Six of the nine studies reported on just CABG; whereas, study 6 and 10 included cardiac surgery, either CABG or valve surgery, and study 14 just included TAVI.  Study 4, 5, and 14 were similar in their aim of assessing the impact of telephone follow-up calls post-discharge.  Study 4 and 5 had six telephone follow-up calls within 25 days post-discharge; whereas, study14 had only two follow-up calls within 30 days post-discharge.  Study 4 and 5 were the same quasi-experimental study conducted in Iran; however, study 4 reported on adherence to treatment plan after CABG and study 5 reported on level of quality of life after CABG.  Study 4 found telephone-nursing follow-up increased patient adherence to discharge treatment plans including adherence to diet, physical activity and exercise, and spirometry use.  Study 5 results indicated that telephone counseling and education increased patients’ quality of life.  Results from study 14, which was conducted in Canada using a non-experimental design, suggest that telephone follow-up after TAVI provides opportunities for a nurse to intervene in patients’ care if required, therefore, supporting a safer transition for patients.  Results also indicated a slight decreasing trend in readmission rates to hospital with the use of these follow-up telephone calls.  All three studies emphasized that the education and information provided to patients before discharge was individually tailored to their learning needs and/or personal situations, and all three showed beneficial outcomes for CABG and TAVI patients who receive follow-up telephone calls after discharge from the hospital.  The similarities in findings are likely due to the similar sample sizes and research design.  However, there were varied amounts and times of delivery of the intervention with study 4 and 5 compared to study 14.  This strengthens the value of the findings and beneficial outcomes resulting from telephone follow-up.   Study 7 examined the effects of follow-up home visits by a nurse practitioner for patients after CABG.  This observational, cohort study was set at a single site in New York, USA with a large sample of 401 CABG patients.  Data was collected via the New York Cardiac Surgery Reporting System and The Society of Thoracic Surgeons databases.  This study found that two additional home follow-up visits from a nurse practitioner after CABG, compared to just one follow-up phone call, were associated with decreased hospital readmission rates and lower death rates.     36  Five studies examined the effect of specialized education for patients prior to discharge from the hospital.  This specialized education included additional educational booklets/teaching provided to patients (study 6, 10, and 11), peer education sessions prior to surgery (study 13), and/or individualized education specific for each patient (study 15).  Sample sizes varied on average from as low as 48 patients to as high as 349 patients.  Three of the five studies reported on CABG except for study 6 and 10 which also incorporated cardiac valve surgery. The five studies used different methods of data collection via questionnaires or assessments and data collection points varied.  On average, data was collected at baseline to as long as eight months post-discharge.  Study 15 was the only study that collected data while patients were in hospital and had no follow-up post-discharge.   Studies 6, 10 and 11 examined the effectiveness of additional educational booklets/teaching provided to patients while in hospital, with mixed results. Studies 6 and 10 were RCTs, whereas study 11 used a quasi-experimental design. Study 6 found no difference in patients’ pain ratings after providing a pain management booklet to patients prior to discharge.  Patients reported uncontrolled post-operative pain even a year after their cardiac surgery.  This study had multiple data collection points over the course of one year and had the largest sample size of the five studies (N=349), which further strengthened the validity of this study.  These results indicate significant concern for under-management and treatment of pain after cardiac surgery.  Study 10 provided specialized exercise training to patients via booklets and a DVD that was to be continued to be used after discharge.  Results of this study showed patients improved their six-minute walking test distance, heart rate recovery, and level of confidence or self-efficacy towards their walking ability.  Study 11 reviewed the effect of extra education provided by healthcare professionals two to three times a day from admission to discharge for the intervention group.  This group was also provided with an education booklet and had access to healthcare professionals via telephone while in hospital and once discharged.  Findings from this study indicated that patients improved in self-care management regarding exercise, diet, personal hygiene, quitting smoking, and wound care.  As well, patients had improved physical exams with increased control over blood pressure for example.  Lastly, because the intervention group experienced significantly lower complications such as edema, there were less unintended hospital readmissions compared to the control group.   37 Studies 13 and 15 were RCTs conducted in Iran and Turkey, respectively. Study 13 assessed the effectiveness of two peer education sessions delivered in-hospital, prior to CABG, on patients’ transitions and readmission rates after CABG.  Results indicated the intervention group had increased levels of cardiac self-efficacy after discharge which included control of symptoms and management of self-care.  There was also a reduction in hospital readmission rates which could be due to the increase in self-efficacy. Study 15 found that providing daily, individualized education tailored to patients’ specific learning needs (from hospital admission to discharge) reduced patients’ anxiety while in hospital and reduced anxiety about patients’ self-care needs after discharge. Despite differing methods, study settings, and sample sizes, with the exception of study 6, all studies demonstrated that the interventions provided to patients supported and facilitated a safe transition from hospital to home.  Studies 7, 11, 13 and 14 also showed decreased hospital readmissions due to the interventions.         38 Chapter 4: Discussion and Conclusion This integrative review sought to answer three research questions regarding patient experiences of transitions, predictors or risk factors associated with poor transitions, and the effectiveness of interventions aimed at reducing poor transitions and/or hospital readmissions.  Of the 15 studies reviewed, 13 of the studies’ findings revealed information on how to support and facilitate a safe transition from hospital to home for elderly patients after elective, invasive cardiac surgery or TAVR/TAVI.  The most significant findings are discussed and categorized into each research question below.  Key Findings Research Question 1: Five studies reviewed patient experiences of transitions after invasive cardiac surgery in relation to frequency of symptoms experienced, management strategies used to reduce symptoms, most frequent learning needs, experiences of depression, and what practices facilitated or hindered the discharge process.  Study 2, 3, and 12 found that pain was identified as the most frequent symptom that patients experience after CABG.  Medication management was the most frequently used symptom management strategy and wound care was identified as the most common learning need.  Study 8 identified depression as a moderately frequented experience by patients after CABG surgery.  Study 9 revealed development of a therapeutic nurse-patient relationship was one important facilitator in a successful transition for patients.  Overall, these five studies describe patients’ varied experiences about the discharge process.  Many of the experiences detail patients’ concerns and negative feelings that can result after their discharge and, thus, affect their transition.  For instance, study 9 described patients’ experiences of feeling unprepared to return home and unsupported in applying discharge information once at home.  Study 12 indicated patients’ experiences of the transition process was fraught with lack of information and support and could be reason for symptoms and complications experienced after discharge.     Research Question 2: Two studies investigated potential predictors or risks of poor transitions.  Study 1 found there was no association between higher levels of frailty and readmission rates or mortality rates after cardiac surgery.  Study 14 indicated that when patients are non-adherent with their medications, unsuccessful in managing fluid balance, and experience anxiety and/or depression after TAVI, they are at increased risk of a poor transition.      39 Research Question 3: Of the nine studies that assessed the effectiveness of interventions designed to reduce poor transitions and/or readmission rates, all but study 6 found positive results for telephone follow-up, home visit follow-up, and specialized education interventions.   With the use of telephone follow-up after discharge, patients were found to have increased adherence to their treatment plan and an increase in quality of life.  Study 7 found the effectiveness of a home visit follow-up decreased readmission and mortality rates.  Moreover, after introducing a specialized education intervention, findings revealed improvements in patients’ walking distance, heart rate recovery, self-efficacy and self-care.  Specialized education interventions also showed decreased levels of anxiety and less complications post-discharge.  The majority of these interventions were provided to patients within one month after discharge.  Because of the positive results from these interventions, this indicates these interventions yield best outcomes if provided within one month after discharge.   Another significant finding that was highlighted in five of the studies in this integrative review was the importance of individualizing discharge education so as to make it more applicable to each patient.  Tailoring the information to their learning, care, and medical needs, and home situation found it improved the transition for patients.  For instance, study 15 found that customizing education to each patient helped alleviate anxieties about discharge and helped provide realistic expectations of their transition. Lastly, readmission rates were analyzed in five studies.  Four of these five studies showed decreased rates in hospital readmissions.  The main reason for the decrease in rates of rehospitalization was due to the different interventions that were provided to patients.  By providing the interventions, patients had feelings of more support from healthcare professionals, experienced less complications, made improvements in their self-care and had increased self-efficacy, thus eliminating much of the need for patients to return to hospital.   Implications for Nursing Practice Nurses play a pivotal role in patient transitions and are found to be the key healthcare professionals assisting patients and families through their healthcare transitions (Son & You, 2015).  There is considerable pressure on nurses to provide optimal discharge planning to ensure a safe transition for all patients.  However, research indicates the significant issues in the discharge process.  These issues include lack of coordination and communication amongst healthcare professionals, ineffective communication between healthcare professionals and   40 patients and families, inattention to pertinent patient healthcare needs or medical issues, and unsuccessful preparation for patients to discharge to home (Preyde, Macaulay, & Dingwall, 2009).  Therefore, this integrative review’s findings provide some recommendations to help nurses incorporate the current applicable information and evidence into their practice in order to improve the discharge process and facilitate safer transitions for elderly patients after elective cardiac surgery or TAVR/TAVI.  The nursing implications are discussed and categorized into each research question below.  Research Question 1: The findings from the studies about patient experiences indicate the need for nurses to place more emphasis on symptom management within their discharge education.  More specifically, the discharge process should be highlighting how to better manage and control pain after cardiac surgery.  Pain was identified as the most frequently experienced symptom after cardiac surgery.  Related to the symptom of pain, the most common strategy to reduce symptoms was medication management and the most common learning need was wound care.  Pain is likely to be a less experienced symptom when proper medication management and wound care education is provided to patients.  Furthermore, study 6, which addressed research question 3, and reviewed the intervention of providing a pain management booklet at discharge, did not result in any improvements in pain ratings or pain control for patients after discharge.  Therefore, this result indicates even further reason for nurses to focus on pain control and pain management when discharge planning for these patients. Nurses also need to be aware of the positive impact that therapeutic nurse-patient relationships have on their patients and their transitions.  The extra time spent with patients developing a discharge plan and incorporating patients’ learning needs and applicable information into patient teaching, helps patients acquire the appropriate knowledge and skills to self-manage their care needs (Veronovici et al., 2014).  This extra time spent with patients can help develop a strong, trusting relationship between nurse and patient.  In turn, the nurse is potentially able to help reassure patients and alleviate many of the worries and uncertainties that have been associated with the discharge process.  Research Question 2: Nurses need to be aware of the risks or predictors that can cause poor transitions for patients.  In study 14, the risks identified were medication non-compliance, poor fluid management, and occurrences of anxiety and depression.  Previous research indicates similar risks that have resulted in poor outcomes for hospitalized patients transitioning to home.    41 Lapum, Yau, and Church (2015) indicated psychological symptoms such as depression and anxiety are commonly experienced in the recovery process and have been linked with worse outcomes for heart surgery patients.  Confusion and lack of understanding about medications has also been identified as a frequent occurrence after discharge which in turn creates further challenges for patients in their transition (Barnason, Zimmerman, Nieveen, Schulz, & Young, 2012).  Thus, it would be essential for nurses to liaise closely with pharmacists and other healthcare professionals to improve the education and planning for medication management for patients.  Additionally, nurses who can address psychological factors such as depression and anxiety in patients will potentially help alleviate any patient concerns that may be contributing to their depression or anxiety.  Nurses who are aware of these risks or predictors and who can address them in the discharge process, will possibly help avoid them from occurring during patient transitions. Research Question 3: Eight studies in this SPAR project identified interventions including telephone follow-up, home visit follow-up, and specialized education that resulted in improved transitions or decreased readmission rates for cardiac surgery and TAVI patients.  It is important for nurses to be aware of the positive outcomes that result from these types of interventions.  However, in order for telephone or home visit follow-ups to be incorporated into discharge planning, nurse staffing levels would need to be adjusted or augmented to cover the increased workload and additional time it would take to implement the interventions.  Thus, it would be important for nurses to be educated on how to make a business case to support requests for additional resources.  Additionally, nurses would have to be provided sufficient education in order to learn how to implement these interventions effectively.  The interventions discussed in this integrative review reveal positive outcomes for patient transitions; thus, there is good reason to include and implement these into nursing discharge practices.  Implications for Future Research  Only 15 studies were found after a comprehensive literature search was performed on this SPAR topic.  This indicates there is limited research on this topic.  Additionally, of these 15 studies, 2 pairs of studies, study 2, 3 and study 4, 5, were the same studies that reported on different analyses.  The majority of the studies were conducted in non-western countries so the results would not necessarily be generalizable outside of their settings.  It would be necessary to further the research within Europe and North America.   42 Minimal research specific to the older, elderly population (greater than 80 years of age) in relation to cardiac surgery or TAVR/TAVI resulted even after a search strategy was employed to try to pinpoint patients greater than 80 years of age.  This strategy involved using keywords such as “elder* OR senior* OR gerontology* OR geriatric*” and medical subject headings “aged” OR “aged 80 and over” OR “frail elderly”.  Despite this strategy, it still resulted in limited hits for studies that addressed this older population.  This lack of literature is concerning as the population is aging and cardiac disease rates are increasing.  Consequently, there is a growing need for octogenarians (people aged greater than or equal to 80 years of age) to have cardiac surgeries (Wang et al., 2014).  These octogenarians have unique healthcare needs compared to the general elderly population.  They require more hospital resources due to multiple medical concerns and co-morbidities (Preyde et al., 2009).  Therefore, they are considered a vulnerable patient population and their recovery following invasive cardiac surgery or TAVR/TAVI can be a challenging time for them (Wang et al., 2014).  More research specific to the older, elderly population is necessary to understand the effect these vulnerabilities have on patients and their transitions.  Likewise, further research will in turn, provide information and evidence on how to support these patients in experiencing a safe transition. Of the 15 studies included in this integrative review only one study addressed TAVI.  This also shows a significant lack of literature for anything other than CABG or cardiac valve surgery.  TAVR/TAVI is being performed more frequently in the older elderly due to the aging population and natural history of aortic stenosis (McCalmont, 2014).  It is also becoming common for many TAVR/TAVI patients to be discharged faster from the hospital within two to four days (Barbanti et al., 2017).  Despite successful post-operative outcomes for patients after TAVR/TAVI, elderly patients still face a challenging recovery (McCalmont, 2014).  Additional literature for TAVR/TAVI procedures would help highlight what specific post-operative and discharge care needs are for these patients, especially after the increasing occurrences of accelerated discharges.  Finally, the majority of these studies captured their data, on average, at two points of time after patients were discharged.  These two data collection points were within a three month time period after discharge.  It would be beneficial to have further research within this three month time frame but it would also be necessary to have more data collected over multiple intervals   43 after discharge and evaluate outcomes over a longer period of time.  This would provide stronger and more reliable results that could be applied to the greater population.    Strengths and Limitations of this Study  Strengths of this integrative review included an in-depth literature search that was completed via three databases using a systematic search criterion with the help of the health sciences librarian.  Additionally, with using three research questions, it considerably narrowed the topic and allowed for precise selection of inclusive studies and quality literature was identified.  Finally, all of the studies are the most current research from within the last five years and capture any recent changes in approaches or best practices that support and facilitate patient transitions. Some limitations of this integrative review were that only 15 quality studies were found relevant to the purpose of this SPAR.  This provides limited insight and evidence that can be applied towards the topic of this SPAR.  The elderly population were not represented within these 15 studies either as only one study reviewed patients 80 years and older.  Instead, the majority of the studies analyzed patients with a mean average age of 65 years.  Furthermore, the majority of studies exclusively reviewed cardiac surgery and only one study reviewed TAVI patients.   Knowledge Translation: From Evidence to Practice    The Registered Nurses’ Association of Ontario [RNAO] (2014) developed a clinical best practice guideline tool that outlines recommendations on how to promote continuity of care and safe, effective transitions for patients.  With the use of this tool, evidence and findings from this integrative review could be disseminated and implemented into nursing practice with the goal of helping support and facilitate safe transitions for patients.     In order to apply this information from this integrative review into practice, nurses would first have to focus on assessing care transitions at the start of a patient’s admission.  This would allow nurses time to gather information specific to patients and at the same time, start the development of a therapeutic nurse-patient relationship.  Information gathered from patients can then be used to tailor specific discharge education to their individual care needs.  Next would be collaborating with all necessary healthcare professionals involved in this patient’s care to start developing a transition plan that is applicable to each patient’s care needs.  Finally, the implementation stage would involve educating the patient regularly over their hospitalization and   44 encouraging their ability in self-care after discharge.  This would also be a time for reviewing medications, liaising with pharmacists, and disseminating knowledge about medication management for patients (RNAO, 2014).  Duration of hospitalization is becoming increasingly shorter and nurses have limited time due to heavier workloads and budget restraints (Sacks et al., 2015).  Therefore, in order to implement evidence-informed approaches and best practices, organizational restructuring and policy development will need to occur in order to provide the resources to support nurses and healthcare professionals with care transitions (RNAO, 2014).  For instance, telephone follow-up after discharge and home visits after discharge have been shown to improve transitions for elderly patients after cardiac surgery.  These types of interventions are beneficial to patient care but would involve adjusting staffing levels in organizations in order to accommodate the added time and workload for this type of follow-up.  Additionally, on-going education to staff on care transitions, as well as within professional nursing institutions, needs to be emphasized in order for nurses to engage in effective coordination of discharge planning and care transitions (RNAO, 2014).  Nurses must be aware of the most current, best standardized education tools in order to disseminate the right information to patients and communicate to them in the most effective way possible.    Conclusion   Transitioning home after a hospitalization can be a challenging time for patients.  Adjusting to new healthcare needs, changing regular routines, and implementing discharge education and instruction once at home can be confusing and overwhelming for patients.  Many patients do not cope well with this transition and subsequently may have to return to the hospital for follow-up (Eldercare Locator, 2011).  Due to hospital stays being shorter, elderly patients are discharged home quicker and in weaker conditions; thus, they are at increased risk of poor outcomes during this transition (Naylor et al., 1999).     This integrative review highlights approaches or best practices that if incorporated into discharge planning and/or further investigated, may help improve care transitions for elderly patients after invasive cardiac surgery or TAVR/TAVI.  Nurses need to be more aware of why poor transitions are occurring and need information and solutions on ways to mitigate these poor transitions.  In order for nurses to implement these approaches and best practices, on-going education, organizational restructure, and changes or developments in policy may be required.    45 Lastly, this SPAR project has emphasized the gap in literature on this topic and for this population of patients.  Care transitions for the elderly are an important issue in healthcare. 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