Post-Heart Transplant Education Outpatient Screening and Referral: A Quality Improvement Project

After heart transplant, patients are given an overwhelming amount of information before discharge. Studies show that comprehension among hospitalized patients is poor, and, on average, they immediately forget 40-80% of what they are taught, and surgery can further hinder the learning and processing abilities. Multifaceted approaches should be used to help improve knowledge, and ongoing nurse-led education has been shown to improve self-management and early clinical outcomes in heart transplant patients. Providers at a local transplant center did not provide or have a process for ongoing nurse led education for post heart transplant in the outpatient clinic. Clinic staff were given matched pre- and post-education surveys, to determine providers' knowledge, interest, and attitudes toward screening post-heart transplant patients for additional nurse-led education in the outpatient clinic. Retrospective chart reviews assessed the usability of the new workflow. Clinicians who used the new workflow process were given a post implementation survey to assess staff satisfaction and the new workflow's usability and feasibility. The interventions for this project consisted of creating a new discharge binder, and several one-page handouts highlighting information from the binder. The one-page handouts served as a resource for the nurses providing additional education in the outpatient clinic. A screening tool and hot texts were created for standardizing the screening, referral, and documentation. Twenty-two staff members participated in the pre-presentation survey and nineteen participated in the post-presentation survey. The Wilcoxon Sign Test using matched dates from the pre and post education surveys indicated a statistically significant increase in staff confidence in recognizing transplant patients who could benefit from additional nurse-led education. Staff agreed that a good clear process for screening and referring patients was defined. All staff felt the patients found the education helpful, and were satisfied with the education, workflow, and plan to continue the new process. This project provided a process for providers to screen and refer post-heart transplant patients in the outpatient clinic for additional personalized one on one nurse led education. Providing additional education in the outpatient clinic has the potential to demonstrate long-term implications such as reduced outpatient visits, clinical problems and decrease days until the first unplanned hospitalization.

1 Post-Heart Transplant Education Outpatient Screening and Referral: A Quality Improvement Project Cariann Brady, Jennifer Clifton College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III 04/09/2023 2 Abstract Background: After heart transplant, patients are given an overwhelming amount of information before discharge. Studies show that comprehension among hospitalized patients is poor, and, on average, they immediately forget 40-80% of what they are taught, and surgery can further hinder the learning and processing abilities. Multifaceted approaches should be used to help improve knowledge, and ongoing nurse-led education has been shown to improve self-management and early clinical outcomes in heart transplant patients. Local Problem: Providers at a local transplant center did not provide or have a process for ongoing nurse led education for post heart transplant in the outpatient clinic. Methods: Clinic staff were given matched pre- and post-education surveys, to determine providers’ knowledge, interest, and attitudes toward screening post-heart transplant patients for additional nurse-led education in the outpatient clinic. Retrospective chart reviews assessed the usability of the new workflow. Clinicians who used the new workflow process were given a post implementation survey to assess staff satisfaction and the new workflow's usability and feasibility. Interventions: The interventions for this project consisted of creating a new discharge binder, and several one-page handouts highlighting information from the binder. The one-page handouts served as a resource for the nurses providing additional education in the outpatient clinic. A screening tool and hot texts were created for standardizing the screening, referral, and documentation. Results: Twenty-two staff members participated in the pre-presentation survey and nineteen participated in the post-presentation survey. The Wilcoxon Sign Test using matched dates from the pre and post education surveys indicated a statistically significant increase in staff confidence 3 in recognizing transplant patients who could benefit from additional nurse-led education. Staff agreed that a good clear process for screening and referring patients was defined. All staff felt the patients found the education helpful, and were satisfied with the education, workflow, and plan to continue the new process. Conclusions: This project provided a process for providers to screen and refer post-heart transplant patients in the outpatient clinic for additional personalized one on one nurse led education. Providing additional education in the outpatient clinic has the potential to demonstrate long-term implications such as reduced outpatient visits, clinical problems and decrease days until the first unplanned hospitalization. Keywords: heart transplant, patient education, health literacy, hospital readmission, nursing, outpatients 4 Post-Heart Transplant Education: Outpatient Screening and Referral Introduction Problem Description Heart transplant is a treatment option for people with end-stage heart failure, many who are often hospitalized, waiting for an available heart. Over the past 5 years at Intermountain Medical Center (IMC), patients waited between 212-742 days for a heart transplant, and then were hospitalized for an average of 16 days post-surgery (R. Menssen, personal communication, March 9, 2023). At the time of discharge, patients and their caregivers are provided with an overwhelming amount of crucial information to help them succeed at home. However, after a lengthy amount of time awaiting a heart transplant, hospitalization, and recent surgery, a patient’s ability to retain the amount of information provided at discharge can be impaired (Commodore-Mensah, 2012). The amount of information provided to these transplant patients can result in information overload, which can result in gaps in retention and understanding of the vital information provided to help keep them safe at home (Commodore-Mensah, 2012). The first six months after a heart transplant can be challenging for patients and their caregivers. With the help of their caregiver, the patient is responsible for caring for the surgical incision, taking scheduled medications multiple times a day, recognizing signs and symptoms of infection and rejection, and understanding their rigorous appointment schedule, which may include extensive procedures, and frequent lab draws. Patients may miss doses of their medications, testing, and clinic appointments, and post-op instructions are not followed completely. In the past five years, post-transplant readmission rates at Intermountain Medical Center ranged from 29-44%, and, in 2022, 10/29 cardiac transplant patients were readmitted 5 within the first three months (R. Menssen, personal communication, March 9, 2023). Readmission rates are high because patients often do not make crucial lifestyle changes to prevent complications, infections, or rejection of the newly transplanted heart. The actions, or lack thereof, that led to readmission are usually unintentional, and could be decreased or prevented with additional outpatient nurse-led education. Prior to this project, the providers at Intermountain Medical Centers Advanced Heart Failure and Transplant Clinic did not have a clear process to screen, refer, or provide post-heart transplant patients with additional education to help improve their understanding and knowledge about life after heart transplant. Available Knowledge Research shows that patients who undergo heart transplants are subject to lifelong complex treatment regimens that involve frequent interactions with the healthcare system (McIlvenna, 2017). Post-heart transplant care places a tremendous amount of responsibility for medication regime adherence, follow-up appointments, and lifestyle change on the patient (Wayda et al., 2018; Senft et al., 2018). The treatments after a heart transplant affect patients’ activities of daily living and may expose them to challenges, such as those related to their new lifestyle, immunosuppressive medications, and physical problems, such as infections and rejection, and can impact their mental health negatively (Fatma, 2021). Health literacy, or the ability of individuals to obtain, process, and understand basic health information, is necessary for patients to navigate the complex healthcare system and manage their health (Duncan, 2020). The Journal of Heart and Lung Transplantation looked at patients’ health literacy regarding cardiac transplantation information and determined that 33.1% of cardiac transplant recipients had inadequate health literacy (Cajita et al., 2016). Patients with 6 low health literacy may experience follow-up barriers, leading to poor adherence to immunosuppressive medications, higher hospitalization rates, rejection, infection, and negative post-transplant outcomes (Wayda et al., 2018). Many of these complications could be avoided if the patient had a better understanding of the information provided to them. One study found that patients immediately forget 40%-80% of the information they receive during each medical encounter (Richard et al., 2017). Clinicians should be aware that comprehension among hospitalized patients is low, and multifaceted approaches may be useful in improving patient knowledge (Sommer et al., 2018). Repetitive education assists in information retention and understanding and may help to promote adherence to health recommendations and regimes (Mohoney, 2018). Intensive nurse-led education in the outpatient setting has been shown to reduce outpatient visits, minimize clinical problems, and increase the days until the first unplanned hospitalization (Lee et al., 2021). To optimize positive outcomes, education should be ongoing and continuous, and could be used to extend life years after a heart transplant (Mohoney, 2018). Rationale The conceptual framework for this project is Lewin’s theory of changes, which explains the movement of an organization from a known state to the desired state (Hussain et al., 2018). When applied to this project, this theory assisted in moving the organization from its current workflow to a new workflow with a clear screening and referral process for outpatient post-heart transplant patients needing additional education. Lewin’s theory of change uses a 3-stage stepwise process of unfreezing, changing, and refreezing and explains how changes can be mastered (Hussain et al., 2018; Rosca, 2020). 7 The unfreezing stage for this project included planning for the change, creating and modifying patient educational material, and providing structured guidelines and education for staff. The staff education opened discussion and created an awareness as to why change was needed. Surveys were provided to examine the staff’s perception of and interest in the project, as well as identify barriers that may have hindered change. To overcome resistance, the unfreezing stage required proper planning and clear communication with staff (Rosca, 2020). Employee participation is essential for high-quality change and minimizing resistance (Hussain et al., 2018). The change or moving stage is when the change occurs and is often the stage where norms are challenged, and fear can arise (Rosca, 2020). This stage involved implementing the new educational material, screening tools, and referral process. The change stage requires continuous motivation, and removal of barriers or insecurities that may hinder change or staff behavior (Rosca, 2020). Engaging staff is the oldest and most effective strategy in formulating the plan, implementing the process, and motivating change (Hussain et al., 2018). The final stage in this framework is the refreezing stage. In this stage, it is essential to allow staff to repeat the change process until they internalize it, and it becomes a natural cadence (Rosca, 2020). For this project, the refreezing stage took place when the screening and referral process became the standard of care. An additional theory that supplemented Lewin’s theory is the Leans systems approach, which helped to address the complex and iterative process of change, which needs to be managed overtime (Wojciechowski et al., 2016; Rosca, 2020). In this project, Lewin’s theory provided the fundamental principles for change, and Leans provided the additional elements of accountability, communication, employee engagement, and transparency (Wojciechowski et al., 2016). The 8 Lean Systems Approach (LEAN) helped to exemplify a culture where each staff member is involved and empowered to make the change ongoing (Wojciechowski et al., 2016). Specific Aims This quality improvement project aimed to develop and implement a screening tool and education-referral workflow in the outpatient clinic and assess the project’s impact on staff satisfaction. The goal was that the workflow would provide personalized 1:1 nurse-led education for post-heart transplant patients who are less than one-year post-heart transplant. This repetitive education allows patients more time to absorb vital information and improve adherence and understanding of their complex regimen. This project had four specific objectives: 1) assess the current barriers in identifying and referring post-heart transplant patients for more intensive nurse-led education; 2) develop a standardized workflow for the screening and referral process, including new patient materials in English and Spanish; 3) implement the workflow in the outpatient clinic, and; 4) evaluate the usability and feasibility of the new standardized workflow for screening and referring post-heart transplant patients for additional education in the outpatient clinic and the staff’s satisfaction with educational handouts. Methods Context Intermountain Medical Center is a large urban 452-bed level one trauma center, in Utah, within the Intermountain Healthcare system. The Advanced Heart Failure and Transplant Clinic is located within the IMC campus and offers inpatient and outpatient services to patients 18 years and older. The heart transplant clinic is part of the U.T.A.H (Utah Transplantation Affiliated Hospitals) Cardiac Transplant Program, which is one of the nation's most successful cooperative heart transplant programs. The program’s unique model utilizes skill, expertise, and resources 9 from four hospitals, including IMC, Primary Children’s Medical Center, University Health Care, and The George E. Wahlen Department of Veterans Affairs Medical Center (Intermountain Healthcare, n.d.). Intermountain heart transplant program has a large multidisciplinary team staffed with physicians, advanced practice providers, nurses, pharmacists, transplant assistants, medical assistants, social workers, financial assistants, and nutritionists. This educational program was implemented within the outpatient Advanced Heart Failure and Transplant Clinic at IMC for patients who were less than a year post-heart transplant and was led by a Doctor of Nursing Practice (DNP) student, with support from the transplant programs leadership and clinic staff. The clinic staff involved in this project consists of 18 advanced practice providers and 11 nurses, whose interest and attitudes were critically important to the success of the project, since the staff actively screen, refer, and provide additional patient education to the post-heart transplant patients in this clinic. Intervention(s) The interventions for this project consisted of a patient screening tool and referral process to provide additional nurse-led education for post-heart transplant patients. Phase 1 of this project, which took place from September to October 2022, and involved informal discussions to assess barriers, interests, and attitudes toward screening and referring post-heart transplant patients for additional education. During phase 2, which also took place September-October 2022, the DNP student created a new discharge binder that was patient and center specific and developed several one-page handouts (in English and Spanish) highlighting education provided in the discharge binder. The one-page handouts served as a resource for the nurses providing additional education in the outpatient clinic. A working group led by the DNP student consisting 10 of two nurses, two providers, and the quality consultant was formed to create a screening tool and hot texts for the electronic medical record. Phase 3, or the implementation phase, took place in October-November 2022. The DNP student provided education to the staff at a monthly staff education meeting and utilized pre-andpost-education surveys to assess the staff’s knowledge, interests, and attitudes toward referring the post-heart transplant patients for additional education. After the presentation, they were given time to ask questions and voice any concerns. Phase 4 of this project took place January-February 2023, and involved retrospective chart reviews that provided data on how many patients were screened, referred, and received additional education. Additionally, a post-implementation survey was given to staff to assess the new workflow for usability, feasibility, and satisfaction. Study of the Intervention(s) The impact of the intervention of this quality improvement project was assessed using pre-and-post education surveys (see Appendix A and B), sent to staff through their work email, and chart reviews. The surveys were used to evaluate the staff demographics and their attitudes and experience with post-heart transplant patients. Retrospective chart reviews provided information on the usability of the intervention. A third survey (see Appendix C and D) was conducted 12 weeks after the workflow was implemented, to assess the provider and nurse satisfaction and perception of the intervention’s usability, feasibility. A pre-educational survey was provided before presenting the quality improvement project, assessed providers’ current knowledge, interests, and attitudes about the need for a clear screening and referral process for post-heart transplant patients to receive additional nurse-led education in the outpatient clinic. A post-education survey was sent after the presentation and 11 was used to evaluate the effectiveness of the presentation and the provider and nurses’ confidence in using the new workflow process. The provider and nurses’ satisfaction and perceptions of usability and feasibility were assessed three months after project implementation. Chart reviews were completed three months after the implementation of the quality improvement project to assess the usability of the new screening, referral, and education workflow. Before this project was implemented, there was no formal process for screening patients, referring them to education, or utilizing specific educational tools. Based on the pre-intervention context, any increase in screening, referral, or additional education resulted from this intervention. The expected outcome of this project was a standardized screening and referral process for providers, for ongoing personalized one on one nurse-led education to post-heart transplant patients in the outpatient clinic. No changes were made in until February 2023 to ensure that the results reflect the original implementation of the new screening, referral, and patient education workflow. Measures Several modified Likert scales were developed and used for data collection. The heart failure and transplant providers’ and nurses took a pre-educational survey (Appendix A) with questions to determine their knowledge, interest, and attitudes towards screening post-heart transplant patients for additional education, as well as questions addressing perceived error rate and referral rate for education. These questions were on a five-point Likert scale, ranging from “strongly disagree” to “strongly agree”. The post-education survey (Appendix B) asked questions about effectiveness of the educational presentation, staff confidence in utilizing the workflow, and offered one-on-one training, and was based on a five-point Likert scale, ranging from “strongly disagree” to “strongly agree”. The post-education asked qualitative questions to 12 assess perceived barriers, which were analyzed to determine common themes and concerns with the new screening, referral, and education process. Acceptability and feasibility were initially assessed in informal meetings with content experts and the advances heart failure and transplant leadership team to determine the value of the project, which was then presented to clinic staff, and implemented. The usability, feasibility, and satisfaction of providers (see Appendix C) were measured using 10 questions with the response choices of ‘Yes,’ ‘No,’ ‘Undecided,’ and ‘I did not have the opportunity to use the process processes (Table 3). The usability, feasibility, and satisfaction of the nursing staff (see Appendix D) were measured using five questions, with response choices of ‘Yes,’ ‘No,’ ‘Undecided,’ and ‘I did not have the opportunity to provide any education to the post-transplant patients’ (Table 4). All staff were asked follow-up questions about the frequency of use, barriers to use, the intent to continue using the process, and any changes that could increase efficiency in the workflow. Completion of the surveys was optional. Analysis Several types of analysis were used to draw inferences from the data collected. Descriptive statistics were used to determine the demographic data from staff participating in this project, and the variables used appropriate summary statistics for central tendency and variability. Descriptive analysis was used to study the retrospective chart audits. The Wilcoxon Sign Test was used to compare matched pre-training and post-training scores to determine a change in perceptions on screening, referring, and providing additional education in the outpatient clinic. Content analysis was conducted on the open-ended question in the posteducation survey, and keywords and themes were identified, and then coded/categorized, organized, and summarized. Descriptive statistics were used to determine the usability, 13 feasibility, and satisfaction of staff, and content analysis was done on open-ended questions that addressed usability, feasibility, and satisfaction. Content analysis revealed keywords and themes, addressing increased efficiency, process improvement, and barriers. Ethical Considerations This project was a quality improvement project in nature and not subject to the Intermountain Health Institutional Review Board (IRB) oversight. There were no conflicts of interest concerning this study. Results Quantitative Results Thirty-one staff members at the Intermountain Advanced Heart Failure and Transplant clinic received the initial demographic survey (Appendix A) through a work email, and 74% (n=23) completed the survey. After three email attempts a total of 8 members could not be reached to complete the initial survey. Of the 8 staff members who did not complete the initial survey 10% (n=3) were full-time staff and 16% (n=5) were PRN staff. Twenty-three staff members received the pre-and post-education surveys on the day of the staff presentation, and 96% (n=22) completed the pre-survey and 83% (n=19) completed the post education survey (Table 2). The pre-and post-education data was matched, and the Wilcoxon Sign Test was conducted to determine the staff’s perceptions of the need for additional education to post-heart transplant patients. The pre-and post-education surveys assessed the providers and nurses’ confidence in their ability to recognize and use the new workflow for screening and referring to additional nurse-led education. The analysis showed an increase in five of the seven (71%) measures (Table 2). 14 Eleven providers received the usability, feasibility, and satisfaction survey, and 73% (n=8) completed the survey. The results showed that all providers found it easy to use the screening and referring process and none felt it was too time-consuming, 88% (n=7) were satisfied with the screening and referral process 12% (n=1) was undecided. All providers felt that the education provided by the nurses was useful and their perception was patients found it helpful. All providers plan to continue to refer patients for additional education. Eleven nurses received the usability, feasibility, and satisfaction survey with 100% completion. The results indicated that the all the nurses felt the education was useful, they found the handouts helpful, they would like to continue providing education and they perceived that their patients found it helpful as well. (Table 3 & 4). Qualitative Results The post-intervention survey (see Appendix C and D) had qualitative questions to assess perceived barriers to the education process, and content analysis was conducted to determine themes and repeated barriers. Content analysis identified that time (33%) and communication concerns between staff (17%) were the most common barriers, and difficulty in a change of process (<1%), and reminders about the change (<1%) were not common only identified as barriers. An additional concern was expressed that the patients may resist staying to receive additional education (11%). Content analysis was also completed on the open-ended questions in the usability, feasibility, and satisfaction, to determine themes regarding ways to increase efficiency, improve the process, or reduce barriers. Several suggestions from providers were made on how to improve the process including ongoing reminders as this becomes a part of everyday patient care, setting future reminders if the recommended education date does not work out on the day 15 the patient is in the clinic, and having the MA send the screening message to the nurses. The barriers noted by providers were forgetting the process, awareness, and time. The suggestions for process improvement from the nursing staff included future education reminders, including education to the discharge schedule, eliminating screening and referral from the providers, and increased education timing alerts between nurses and providers. To increase efficiency nurses suggested re-engaging providers, eliminating providers, and nursing to provide education while providers discuss the patient with MD. The nurses noted inconsistency among providers, and providers forgetting to screen and refer patients for education and barriers. Chart Review Over the course of 45 business days there were 37 opportunities for screening and referrals for nurse-led education. Retrospective chart reviews showed 76% (n=28) of the screening and referrals were completed, and of these, all 100% (n=28) cases received nurse-led education. Because there was no screening and referral process prior to this intervention, the goal was to screen and refer 50% of opportunities, and this goal was surpassed. Unintended Consequences The staff was surprisingly responsive to the project and has discussed utilizing the screening and referral process for other outpatient populations in the clinic who may benefit from disease specific nurse-led education. The clinic works with various types of heart failure including heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), hypertrophic obstructive cardiomyopathy (HOCM), hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), familial cardiomyopathy (FCM), peripartum cardiomyopathy (PCM), chemotherapy-induced 16 cardiomyopathy and many others. Specifically, with new consultations to the clinic a similar screening and referral could be placed to the nurse coordinators to provide disease-based instructions to patients with developed educational material. Discussion Summary This project was designed to develop and implement a screening and referral workflow to provide additional education for post-heart transplant patients in the outpatient clinic at IMC, in Utah. The results of this project demonstrated a statistically significant increase in providers’ confidence in their ability to effectively recognize need, screen patients, and refer post-heart transplant patients for additional nurse-led education. The results also showed providers were satisfied with the screening and referral process and plan to continue to use the new workflow. The nurses provided education to all patients who were referred for education and would like to continue providing education in the outpatient clinic. All staff felt the education provided was useful and helpful to the patients. The staff identified the need for frequent reminders about the new process until it becomes integrated into the workflow and inconsistencies among providers screening and placing a referral as barriers to success. To increase efficiency the timing of the nurse education could be done while the provider and MD discuss a follow-up plan for the patient. This project was strengthened by the high degree of acceptance and support of the staff and the department. The providers were committed to utilizing the screening tool and placing the referral for additional nurse education. The nursing staff were also highly engaged and enthusiastic and provided education to all of the referred patients. The informal feedback from the providers and nursing staff during the implementation of the new workflow was positive, and 17 nursing staff found the new patient education binder with the additional one-page educational handouts helpful when providing education (Figures 1-5). Interpretation No current literature that analyzed the understanding and satisfaction for providers and nursing staff on screening and referring post-heart transplant patients for additional nurse-led education was found. However, one study demonstrated that additional outpatient education can reduce outpatient visits and clinical problems and increase days until the first unplanned hospitalization (Lee et al., 2021). Additionally, strategies used to improve patients’ disease knowledge and understanding lead to improved medication adherence, increased personal responsibility of health outcomes, improved lifestyle choices, better self-efficacy, and quality of life (Dineen-Griffin et al., 2019). This project created a screening and referral process to provide additional nurse-led education to post-heart transplant patients. This study impacts patients who have undergone heart transplant by enhancing their knowledge and understanding about their responsibilities and posttransplant treatment plan. This also impacts the providers and nurses of The Advanced Heart Clinic and Transplant Clinic at IMC, by enabling them to provide more comprehensive information to patients without significantly increasing their workload or burden. The usability, feasibility, and satisfaction of staff were high. All the providers found the screening and referral process easy to use and not too time-consuming, and all providers plan on continuing to use this workflow. The monetary cost of this project is minimal and includes printing costs for the individual handouts. There was a one-time cost associated with translating the handouts into Spanish. Intermountain recently rebranded its look so there will be some time required to update the 18 education handouts with the rebranding style, so they are consistent with the educational material that is provided. Limitations There are several limiting factors to the generalizability of this project. Post-heart transplant patients represent a highly specific population, so this project cannot be generalized to society, and the sample size was small, so these findings might not apply to all post-heart transplant patients. The demographics and context also limit generalizability. This study was conducted in Salt Lake City, Utah, a largely homogenous population, and the staff surveyed were primarily white, female, and cisgender. These results should not be generalized outside of the population included in the project. The results of this project could be skewed if there were any inaccurate answers given in the surveys causing any response bias. Efforts were made to minimize bias by avoiding double-barreled questions and making the survey anonymous. Conclusions The findings of this quality improvement project suggest that the staff found the screening and referral workflow and nurse-led education to be beneficial to patients, and that the process was easy to implement, and was worth continuing after the project ended. The nursing staff indicated that they feel the educational handouts were helpful and that they hope to continue to provide education to post-heart transplants in the outpatient clinic in the future. This project has a high likelihood of sustainability due to ease of use, perceived staff satisfaction, and buy-in from the management, staff, and team leaders at the clinic. The educational handouts have minimal cost, and the team has access to modify, print, and restock them. The next steps would be to update the education material with the new recent 19 Intermountain Health Care branding, which would not be difficult given the ease of access the staff has to the material. This intervention provides ongoing, comprehensive education to post-heart transplant patients in the outpatient clinic, to help close gaps in retention and understanding of the vital information provided to them at discharge. Increasing understanding will improve post-op results, quality of life, and adherence to healthcare instructions, and minimize infections or other risks of surgery. Moving forward future quality improvement project could assess patient satisfaction with the ongoing education in the clinic determine how this education impacts and adherence to recommendations, outpatient visits, unplanned readmissions, or quality of life within the first three months. 20 Acknowledgements I would like to extend my gratitude to all the staff at the Advanced Heart Failure and Transplant Clinic at Intermountain Medical Center, particularly to Stacey Frampton, NP, Amanda Shike, PA-C, Charmain Nemelka, RN for their contributions as content experts. A special thanks to Dr Jennifer Clifton for her oversight throughout the project and to my peers Christina Maruyama and Kat Dembergh for their support. I owe a special thanks to my husband Brett Brady for his support. Finally, my gratitude to my editors Rachael Katz and Michaela Katz. 21 References Cajita, M. I., Denhaerynck, K. Dobbels, F., Berben, L., Russell, Cynthia L., Davidson, P. M., & De Geest, S. (2016). 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The Online Journal of Issues in Nursing, 21(2). https://doi.org/10.3912/OJIN.Vol21No02Man04 24 Table 1: Demographics for Medical Professionals in the Advanced Heart Failure and Transplant Clinic Medical professionals N=23(%) Age (years) 25-34 35-44 45-54 55-64 65+ Gender Male Female Role Provider Nurse Coordinator Medical Assistant Time working in Heart Transplant (years) <1 1-4 5-9 10-14 >15 Primary Workplace Outpatient Inpatient and Outpatient Position Full time Part-time As needed 2 (9%) 11 (48%) 6 (26%) 3 (13%) 1 (4%) 2 (9%) 21 (91%) 11 (48%) 10 (43%) 2 (9%) 2 (9%) 4 (17%) 10 (44%) 3 (13%) 4 (17%) 9 (39%) 14 (61%) 21 (92%) 1 (4%) 1 (4%) 25 Table 2: Provider and Nurse Survey Results Likert Survey Pre-Survey N=18 (%) Post-Survey N=18 (18%) Post-heart transplant patients should be screened and referred for additional outpatient education within heart transplant practices like mine. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 0 (0%) 0 (0%) 0 (0%) 5 (28%) 13 (72%) 0 (0%) 0 (0%) 0 (0%) 3 (17%) 15 (83%) P Value* p> 0.05 Post-transplant patients in the outpatient clinic could benefit from the additional education a transplant coordinator provides. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 0 (0%) 0 (0%) 0 (0%) 6 (33%) 12 (67%) 0 (0%) 0 (0%) 0 (0%) 2 (11%) 16 (89%) I feel confident in my ability to effectively recognize post-heart transplant patients in the outpatient clinic who would benefit from additional teaching. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 0 (0%) 0 (0%) 2 (11%) 13 (72%) 3 (17%) 0 (0%) 0 (0%) 0 (0%) 7 (39%) 11 (61%) p> 0.05 p< 0.05 26 I feel confident in knowing how to refer post-heart transplant patients for additional education. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree We have a good, clear process for screening post-heart transplant patients for additional education. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree We have a good clear process for referring post-heart transplant patients for additional education. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree We have a good clear process for providing additional nurse education for outpatient post-heart transplant patients. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree p< 0.05 0 (0%) 4 (23%) 2 (11%) 6 (33%) 6 (33%) 0 (0%) 1 (5%) 0 (0%) 5 (28%) 12 (67%) p< 0.05 1 (5%) 10 (56%) 2 (11%) 3 (17%) 2 (11%) 0 (0%) 1 (5%) 0 (0%) 7 (39%) 10 (56%) p< 0.05 2 (11%) 5 (28%) 6 (33%) 3 (17%) 2 (11%) 0 (0%) 1 (5%) 0 (0%) 7 (39%) 10 (56%) p< 0.05 0 (0%) 6 (33%) 4 (23%) 6 (33%) 2 (11%) 0 (0%) 1 (5%) 0 (0%) 7 (39%) 10 (56%) * Values were calculated using the Wilcoxon Signed-Rank Test and a p-value of <0.05 was used as a benchmark 27 Table 3: Usability, Feasibility, and Satisfaction Provider Survey Results Likert Survey Provider N=8 (%) Over the past few months, how many patients did you see in the clinic that were under oneyear post-transplant? 0 1-3 4-5 >6 0 (0%) 0 (0%) 4 (50%) 4 (50%) Of those transplant patients, how many did you use the screener on the chart to refer for additional nurse-led education? None Some Most All 1 (12%) 3 (38%) 3 (38%) 1 (12%) Of those transplant patients, how many did you place a referral in the message center for additional education? None Some Most All 2 (25%) 3 (38%) 1 (12%) 2 (25%) Do you feel the post-transplant education provided by the nurses is useful? Yes No Undecided I did not have the opportunity to use the process 8 (100%) 0 0 0 Do you feel the patients found the education helpful? Yes No Undecided I did not have the opportunity to use the process 8 (100%) 0 0 0 Did you find the screening tool on the chart useful? Yes No Undecided I did not have the opportunity to use the process 8 (100%) 0 0 0 Did you find it difficult to use the screener? Yes No Undecided 0 8 (100%) 0 28 I did not have the opportunity to use the process 0 Did you find it difficult to place a referral? Yes No Undecided I did not have the opportunity to use the process 0 8 (100%) 0 0 Do you feel this process was too time-consuming? Yes No Undecided I did not have the opportunity to use the process 0 8 (100%) 0 0 Are you satisfied with the screening tool on the chart? Yes No Undecided I did not have the opportunity to use the process 8 (100%) 0 0 0 Are you satisfied with the referral process? Yes No Undecided I did not have the opportunity to use the process 7 (88%) 0 1 (12%) 0 Do you plan to continue to screen post-heart transplant patients for nurse education? Yes No Undecided I did not have the opportunity to use the process 7 (88%) 0 1 (12%) 0 Do you plan to continue to refer post-heart transplant patients for nurse education? Yes No Undecided I did not have the opportunity to use the process 8 (100%) 0 0 0 Open-ended questions Do you have any suggestions for the future on how to improve the process? What would you change to increase efficiency? What are the barriers you see to continuing to use this process? 29 Table 4: Usability, Feasibility, and Satisfaction Nurse Survey Results Likert Survey Nurse N= 10(%) Over the past few months, did you provide additional nurse education to post-heart transplant patients in the clinic? Yes No 9 (90%) 1 (10%) Do you feel the post-transplant education you provide in the clinic is useful? Yes No Undecided I did not have the opportunity to provide any education to the post-transplant patients 10 (100%) 0 (0%) 0 (0%) 0 (0%) Did you find the one-page handouts to be helpful? Yes No Undecided I did not have the opportunity to provide any education to the post-transplant patients 10(100%) 0 (0%) 0 (0%) 0 (0%) Would you like to continue providing education in the clinic? Yes No Undecided I did not have the opportunity to provide any education to the post-transplant patients 10(100%) 0 (0%) 0 (0%) 0 (0%) Do you feel the patients found the education helpful? Yes No Undecided I did not have the opportunity to use the process 9 (90%) 0 (0%) 0 (0%) 1 (10%) Open-ended questions Do you have any suggestions for the future on how to improve the process? What would you change to increase efficiency? What are the barriers you see to continuing to screen and refer patients for nurse education? 30 Figure 1 Developed 1-page education for nurse-led education that references discharge binder. 1-week post-discharge education sheet 31 Figure 2 Developed 1-page education for nurse-led education that references discharge binder. 3-week post-discharge education sheet 32 Figure 3 Developed 1-page education for nurse-led education that references discharge binder. 2-month post-transplant education sheet 33 Figure 4 Developed 1-page education for nurse-led education that references discharge binder. 4-months post-transplant sheet 34 Figure 5 Developed 1-page education for nurse-led education that references discharge binder. 9-month post-transplant education sheet 35 Appendix A Provider and Nurse Screening and Referral Pre-Educational Survey Demographics 1. Age (18-24, 25-34, 35-44, 45-54, 55-64, 65+, I prefer not to answer) 2. Gender (male, female, I prefer to self-describe) 3. What is your role (provider, nurse coordinator, medical assistant, another role please specify) 4. How many years have you practiced in heart transplantation (less than a year, 1-4 years, 5-9 years, 10-14 years, >15 years) 5. Primary workplace (outpatient, inpatient, inpatient, and outpatient, nonclinical) 6. Which best describes your position (full-time, part-time, as needed) Screening and Referral Survey 1. About what percent of post-heart transplant patients have you seen in the past twelve months that you believe had errors after discharge? (about 10%, about 25%, about 50%, about 75%, about 90% , >90%, don’t know) 2. About what percent of patients have you screened, referred, or given additional nurse-led education in the outpatient clinic in the past twelve months? (about 10%, about 25%, about 50%, about 75%, about 90%, don’t know) 3. Post-heart transplant patients should be screened and referred for additional education within heart transplant practices like mine. 4. Post-heart transplant patients in the outpatient clinic would benefit from the additional education a transplant coordinator could provide. 36 5. I feel confident in my ability to effectively recognize post-heart transplant patients in the outpatient clinic who would benefit from additional teaching. 6. I feel confident in knowing how to refer post-heart transplant patients for additional education. 7. We have a good clear process for screening post-heart transplant patients for additional education. 8. We have a good clear process for referring post-heart transplant patients for additional education. 9. We have a good clear process for providing additional nurse education for outpatient post-heart transplant patients. 37 Appendix B Provider and Nurse Post-Presentation Survey 1. The information at the presentation provided me with an understanding of why screening and referral for additional education for post-heart transplant patients are needed. 2. Post-heart transplant patients should be screened and referred for additional outpatient education within heart transplant practices like mine. 3. Post-heart transplant patients in the outpatient clinic could benefit from the additional education a transplant coordinator provides. 4. I feel confident in my ability to effectively recognize post-heart transplant patients in the outpatient clinic who would benefit from additional teaching. 5. I feel confident knowing how to refer post-heart transplant patients for additional education. 6. We have a good clear process for screening post-heart transplant patients for additional education. 7. We have a good clear process for referring post-heart transplant patients for additional education. 8. We have a good clear process for providing additional nurse education for outpatient post-heart transplant patients. 9. I would like additional one-on-one training on the new screening and referral process. (yes, no) 10. What barriers (e.g., time, complexity, technology, staff) do you see in screening, referring, and providing additional education to the post heart transplant patients? 38 Appendix C Provider Usability, Feasibility, and Satisfaction Survey 1. Over the past few months, how many patients did you see in the clinic that were under one-year 1-3 post-transplant? (0, 1-3, 4-5, >6) 2. Of those transplant patients, how many did you use the screener on the chart to refer for additional nurse-led education? (none, some, most, all) 3. Of those transplant patients, how many did you place a nonreferral in the message center for additional education? (none, some, most, all) 4. Did you find the screening tool on the chart useful? (Yes, No, Undecided, I did not have the opportunity to the process) 5. Do you feel the post-transplant education provided by the nurses is useful? (Yes, No, Undecided, I did not have the opportunity to the process) 6. Do you feel the patients found the education helpful? (Yes, No, Undecided, I did not have the opportunity to the process) 7. Did you find it difficult to use the screener? (Yes, No, Undecided, I did not have the opportunity to the process) 8. Did you find it difficult to place a referral? (Yes, No, Undecided, I did not have the opportunity to the process) 9. Do you feel this process was too time-consuming? (Yes, No, Undecided, I did not have the opportunity to the process) 10. Are you satisfied with the screening tool on the chart? (Yes, No, Undecided, I did not have the opportunity to the process) 39 11. Are you satisfied with the referral process? (Yes, No, Undecided, I did not have the opportunity to the process) 12. Do you plan to continue to screen post-heart transplant patients for nurse education? (Yes, No, Undecided, I did not have the opportunity to the process) 13. Do you plan to continue to refer post-heart transplant patients for nurse education? (Yes, No, Undecided, I did not have the opportunity to the process) 14. Do you have any suggestions for the future on how to improve the process? (Open-ended question) 15. What would you change to increase efficiency? (Open-ended question) 16. What are the barriers you see to continuing to use this process? (Open-ended question) 40 Appendix D Nurse Usability, Feasibility, and Satisfaction Survey 1. Over the past few months, how many post-heart transplant patients did you provide additional education to in the clinic? (Yes, No, Undecided, I did not have the opportunity to provide any education to the post-transplant patients) 2. Do you feel the post-transplant education you provide in the clinic is useful? (Yes, No, Undecided, I did not have the opportunity to provide any education to the post-transplant patients) 3. Did you find the one-page handouts to be helpful? (Yes, No, Undecided, I did not have the opportunity to provide any education to the post-transplant patients) 4. Would you like to continue providing education in the clinic? (Yes, No, Undecided, I did not have the opportunity to provide any education to the post-transplant patients) 5. Do you think the patients found it helpful? (Yes, No, Undecided, I did not have the opportunity to provide any education to the post-transplant patients) 6. Do you have any suggestions for the future on how to improve the process? (Open-ended question) 7. What could be changed to increase efficiency? (Open-ended question) 8. What are the barriers you see to continuing to screen and refer pts for nurse education? (Open-ended question)