El Hospital Severo Ochoa suma enfermera gestora de casos en insuficiencia cardíaca
Administrative assistant for heart failure patients
The heart failure care process was implemented in our area in 2023 with Lean philosophy and Kaizen methodology, incorporating medical and nursing professionals from both levels of care including Primary Care, Emergency, Geriatrics, Internal Medicine, and Cardiology.
A person with heart failure is a complex, chronic, multi-medicated patient who depends on different healthcare professionals. The goal of a trial with patients of these characteristics should always be to allow them to live as long as possible and with the best possible quality of life. As explained by the head of the Cardiology Service at Severo Ochoa Hospital, Inmaculada Fernández, «they are offered this optimal health resource for each moment of their illness, so they require personalized coordination of healthcare and social resources.» In this context, the global vision of the patient becomes fundamental, and this process is the main objective of the case manager nurse’s work.»
Case manager nurse for the heart failure team
The case manager nurse works in the heart failure team at Severo Ochoa Hospital. Her main lines of activity are the daily identification of new diagnoses of pathology at both care levels and the incorporation of patients into the process, the preparation for discharge of the hospitalized patient for decompensation based on specific patient education about their disease, and the establishment of a mixed plan for early face-to-face or telephone follow-up depending on the resource adapted to each patient.
In addition, other important lines such as telephone monitoring of patients at high risk of decompensation are added, which are patients with very frequent hospitalizations, but also patients followed by the cardiology unit with devices capable of generating alarms that anticipate a possible worsening of heart failure. In addition to her role as a case manager nurse, she provides telephone support to patients and other healthcare professionals involved in the process and coordinates nursing activities at the Heart Failure Day Hospital, as well as treatment cycles with intravenous diuretics, treatment with intravenous diuretics at home with subcutaneous elastomer, among others.
According to Sara Corredera, a case management assistant at Severo Ochoa University Hospital, «working in the heart failure team has allowed us to improve the quality of life of patients by reducing hospitalizations, also for heart failure decompensations, as well as visits to the emergency room and risk-adjusted mortality.»
Patients with positive assessment and better quality of life
The implementation of the heart failure cross-trial resulted in an excellent assessment by patients, with data from the last quarter of 2023 scoring nine out of ten. Beyond this very positive figure, the importance of specific examples of patients who have improved their quality of life stands out, such as a patient who was able to go on vacation after several years without being able to do so, all thanks to the work of the case manager with the coordination of elastomer changes at the reference center of his vacation spot.
