State of the Science Quality ImprovementNameInst

State of the Science Quality ImprovementNameInstitutionsDate
Abstract
The condition of chronic heart failure sometimes is referred to
as congestive heart failure (CHF), which is recognized as an
acute life-threatening disease that majorly affects millions of
American citizens annually. The condition of the chronic heart
failure results when the heart is incapable of sufficient pump
the blood throughout the body tissues due to the weak heart
muscles (January et al., 2019). Certain conditions, such as
narrowed arteries in the heart (CAD) or high blood pressure,
gradually leave the heart too weak or stiff to fill and pump
efficiently. Moreover, there are some of the several conditions
such as coronary artery diseases and hypertension that leads to
acute and chronic heart failure in the body system. More

importantly, to avoid the possibility of this dangerous condition
as well as the ever-increasing of the re-admitted hospital
continue, collectively, the patient must be able to control the
earlier stated conditions along with diabetes as well as obesity
at home-based care and with their primary healthcare providers
as well. According to Santesmases-Masana et al. (2019),
"Primary health care planned care has been shown to reduce
heart failure re-hospitalizations and maintain the patient quality
of life." With this known knowledge, it is important to continue
care at home and with their primary care provider to monitor
and detect worsening of their condition sooner rather than later
with evidence-based treatment practices. There are many
evidence-based treatments for chronic heart failure that includes
monitoring of vital signs, weight, and diet along with
medications. In this paper, chronic heart failure, problem
discussion, PICO question, and theoretical framework will be
presented.
Problem Discussion
Chronic heart failure is a chief public health care concern
linked with the high degree of mortality and morbidity in the
U.S. Heart failure usually results in adverse outcomes, and the
most costly is the issues of hospital readmissions. Currently, the
heart failure management clinical procedures and pieces of
evidence emphasizes the significance and the function of the
care interventions a mid preventing the heart failure
readmissions in the hospital set up. The current literature
review is meant to evaluate and assess the effectiveness of
transitional care interventions that intend to minimize hospital
readmissions. Increase hospital readmission and worsening
chronic heart failure complications are due to lack of following
of a primary care provider and home monitoring of vital signs,
weight, diet, energy level, and breathing patterns by the patient.
There are many evidence-based practices and comprehensive
guidelines for chronic heart failure treatment with side effects
of some medications about individual races. For instance,
losartan has little to adverse impact on blacks. Furthermore,

according to Hadidi et al. (2018), "It has been shown that under
prescribing of evidence-based therapies is associated with
worsening heart failure and higher rates of heart failure hospital
admissions and mortality." Unfortunately, as the rate of chronic
heart failure increases due to the aging population's increase,
home monitoring will decline due to mental, physical, and
financial instability and lack of support.
Some of the causes include Heart failure often develops after
other conditions have damaged or weakened the heart. However,
the heart doesn't need to be reduced to cause heart failure. It
can also occur if the heart becomes too stiff. In heart failure,
the main pumping chambers of the heart (the ventricles) may
become thick and not fill appropriately between beats. In some
cases of heart failure, the heart muscle may become damaged
and weakened, and the ventricles stretch (dilate) to the point
that the heart can't pump blood efficiently througho ut the body.
Over time, the heart can no longer keep up with the ordinary
demands placed on it to pump blood to the rest of the body. The
term "congestive heart failure" comes from blood backing up
into or congesting: the liver, abdomen, lower extremities, and
lungs. However, not all heart failure is congestive. Patients
might have shortness of breath or weakness due to heart failure
and lack of fluid building. Heart failure can involve the left side
(left ventricle), right side (right ventricle), or both sides of the
heart. Generally, heart failure begins with the left side,
specifically the left ventricle: the heart's main pumping
chamber.
Signs and symptoms of the problem chronic heart failure
Shortness of breath (dyspnea) when lying down, Fatigue and
weakness, Swelling (edema) in the legs, ankles, and feet, Rapid
or irregular heartbeat, reduced ability to exercise, Persistent
cough or wheezing with white or pink blood-tinged phlegm,
Increased need to urinate at night, Swelling of the abdomen
(ascites), Sudden weight gain from fluid retention, lack of
appetite and nausea, Difficulty concentrating or decreased
alertness, Sudden severe shortness of breath and coughing up

pink, foamy mucus, and Chest pain if a heart attack causes the
heart failure.
Etiology of the chronic heart failure
Coronary artery disease is the most common form of heart
disease and the most common cause of heart failure. Over time,
arteries that supply blood to your heart muscle narrow from a
buildup of fatty deposits, a process called atherosclerosis. The
accumulation of plaques can cause reduced blood flow to your
heart. A heart attack occurs if plates formed by the fatty
deposits in your arteries rupture. This creates a blood clot to
form, which may block blood flow to the heart muscle area,
weakening the heart's pumping ability and often leaving
permanent damage. If the damage is significant, it can lead to a
weakened heart muscle.
Blood pressure is the force of blood pumped by your heart
through your arteries. If your blood pressure is high, your heart
has to work harder than it should to circulate blood throughout
your body. Over time, the heart muscle may become thicker to
compensate for the extra work it must perform. Eventually, your
heart muscle may become either too stiff or too weak to pump
blood effectively. Faulty heart valves. The valves of your heart
keep blood flowing in the proper direction through the heart. A
damaged valve due to a heart defect, coronary artery disease, or
heart infection forces your heart to work harder to keep blood
flowing as it should. Over time, this extra work can weaken
your heart. Faulty heart valves, however, can be fixed or
replaced if found in time.
Damage to the heart muscle (cardiomyopathy). Heart muscle
damage (cardiomyopathy) can have many causes, including
several diseases, infections, alcohol abuse, and the toxic effect
of drugs, such as cocaine or some drugs used for chemotherapy.
Genetic factors play an essential role in several types of
cardiomyopathy, such as dilated cardiomyopathy, the most
common type of cardiomyopathy, causes diffuse myoc
Myocarditis. Myocarditis is an inflammation of the heart
muscle. It's most commonly caused by a virus and can lead to

left-sided heart failure. Heart defects you're born with
(congenital heart defects). If your heart and its chambers or
valves haven't formed correctly, the right parts of your heart
have to work harder to pump blood through your heart, which,
in turn, may lead to heart failure. Abnormal heart rhythms
(heart arrhythmias) abnormal heart rhythms may cause your
heart to beat too fast, which creates extra work for your heart.
Over time, your heart may weaken, leading to heart failure. A
slow heartbeat may prevent your heart from getting enough
blood out to the body and may also lead to heart failure.
Chronic diseases such as diabetes, HIV, hyperthyroidism,
hypothyroidism, or a buildup of iron (hemochromatosis) or
protein (amyloidosis) also may contribute to heart failure. Acute
heart failure causes viruses that attack the heart muscle, severe
infections, allergic reactions, blood clots in the lungs, the use of
certain medications, or any illness that affects the whole body.
On the other hand, Home monitoring is an integral part of
patients with chronic heart failure. However, some patients
cannot mentally process the importance of taking their vital
signs (most importantly, blood pressure) a few times a day and
writing it down. With the aging population, dementia may start
to set in, and they will forget to take their medication and
monitor their blood pressure. They may remember to take their
medication but forget to take their vitals, and their blood
pressure could already below, which will lead to further
complications. Besides, the patient may be physically incapable
of using medical equipment if a support person is not present.
Furthermore, the patient may not be financially able to obtain a
sphygmomanometer, thermometer, pulse oximeter, batteries, or
transportation to their primary care provider. Also, their
finances may not allow them to purchase healthy foods (more
expensive) over non-healthy foods (less expensive) all the time.
Identify the stakeholders impacted by the concern.
The condition of chronic heart failure is a concerning factor for
many stakeholders. Those that are affected by chronic heart
failure along with the patient (primary stakeholder) are their

support system, health organizations, insurance companies,
primary care providers, and nurses. Besides the patient (with
full mental capacity), the support person, nurses, and primary
care provider are best to detect changes in early signs of chronic
heart failure exacerbation of non-specific symptoms
(Harrington, 2019). The primary care provider needs to update
and make patient screenings more patients specific and
supervised them more closely to ensure understanding and
acceptance (Santesmases-Masana et al., 2019). All stakeholders'
full knowledge and cooperation with the recommended
treatment plan for the patient with chronic heart failure are
required for a sustainable and effective outcome of limiting
hospital readmission.
Furthermore, the primary care providers must make sure they
are prescribing the right treatment regime for the patient
because that could increase their mortality rate. Since chronic
heart failure requires significant monitoring and treatments,
proper health insurance is necessary for continued adequate
care. Lack of health coverage will lead to inadequate healthcare
due to high costs. This unfortunate event of not having
insurance will lead to an increase in emergency room visits and
hospital admissions for treatments.
Lack of chronic heart failure monitoring will lead to further
complications and increase hospital stay. According to Hart and
Nutt (2020), "Heart failure (H.F.) contributes to the highest
frequency of 30-day hospital readmissions out of all causes,
raising the already significant risk for adverse outcomes and
costs." Overall, heart failure is increasing with an equally
growing mortality rate. Without proper, patient-specific
education with return clarification, hospital readmission will
continue to rise. Ongoing, updated, and shared knowledge is
required for patients with chronic heart failure to increase home
monitoring and decrease hospitalization. Chronic complications
of heart failure will lead to kidney and liver damage.
Identify a purpose statement.
The aim of decreasing hospital readmission from exacerbation

of chronic heart failure will require the collaboration of
everyone involved with patient care. Education is the first and
most crucial part, starting with the medical team. When
emphasizing self-care and chronic heart failure management
through effective teaching and communication, combined with
follow-ups, hospital readmissions will be minimized (Hart and
Nutt, 2020). Making sure the patient understands and accepts
their current condition is a must for them to be compliant at
home with the required treatment regimen. Next, make sure they
are able to obtain specific medical equipment at home to assess
all their vital signs, most importantly, their blood pressure.
Educate them on the normal ranges so abnormal ranges can be
reported. Make sure they can manipulate the equipment and log
all their results. Lastly, make sure the patient gets started on the
proper diet and able to assess their weight daily. Along with
education, multidisciplinary outpatient programs will be very
beneficial to the patient, so their knowledge of chronic heart
failure and self-care will be sustainable and carried out
(Harvey, 2020).
PICO Question and Review of Literature
PICO statement: With the increasing rates of chronic heart
failure patient hospital admissions (P), how can hospital
readmission are decreased with adequate education and home
monitoring (I), after their diagnosis and initial hospitalization
(C), during the course of the patient's condition (O).
For this quality improvement paper, this author used
Chamberlain University's online Library to access many
databases such as EBSCO Information Services, CINAHL, Pro-
Quest, and Cochrane. Also, the American Heart Association
website was used from the Google search engine. Many search
terms were used that were relevant to the topic, which included:
heart failure, chronic heart failure, stakeholders, insurance
management for heart failure, heart failure education, and heart
failure monitoring. (See The John Hopkins Question
Development Tool in the appendix).
Heart failure is rapidly increasing in the United States. Still,

patients that closely monitor their condition at home leads to
cost-effective care and reduce hospital admissions from
adequately and timely patient education provided by their
provider (Schub & Oji, 2018). The American Heart Association
offers a significant amount of information for heart failure and
patient education. During the initial hospitalization and
diagnosis of heart failure, learning should be initiated
immediately due to the critical role it plays with chronic heart
failure management (January et al., 2019). As the population
grows, chronic heart failure increases within the aging
population due to deterioration of the heart muscle. A slower
progression of the disease can occur with proper self-care
(Wonggom et al., 2020). However, Elkhateeb and Salem (2018)
did research that showed that the correlation between family
support and patient education did not correlate with either
hospital readmissions or mortality rates. Luhr et al., (2018)
researched was done on elderly education and concluded that
the elderly population did not have a more significant outcome
of quality of life when given proper training by their primary
care provider, compared to those with routine care. However,
Hart and Nutt (2020) stated, "As little as one 60-minute,
targeted education session with nurses trained in heart failure is
effective at improving disease knowledge and self-care and
reducing hospital readmissions."
Theoretical Framework
The theoretical framework that will be used for this quality
improvement project is the Situation-Specific Theory of Heart
Failure Self-care that was published in 2008, which shows how
patients with chronic heart failure care for themselves and
manages their condition (Vellone et al., 2019). According to
Vellone et al. (2019), "Self-care was defined as a naturalistic
decision-making process involving the choice of behaviors that
maintain physiologic stability (maintenance) and the response to
symptoms when they occur (management)." With this theory,
there are three areas of focus on self-care maintenance,
symptom perception, and symptom management that helps the

provider assess the patient's mentality on their condition (Hart
and Nutt, 2020). This theory has been previously used and can
be used and applied to this improvement project on chronic
heart failure by describing the patient's current situation with
chronic heart failure, showing how the elements are congruent
to each other, and predicting the future/outcomes; however,
further research is needed (Vellone et al., 2019).
Conclusion
Chronic heart failure is a condition that is ever-increasing in
rates globally, with increase hospital readmissions and mortality
rates, especially among the older population. To reduce the
advancement of this condition and have better control,
collectively, the patient must have sufficient full knowledge of
self-care and education on chronic heart failure (Wonggom et
al., 2020). Many factors play a vital role in chronic heart failure
monitoring and maintenance. The patient must remember to
attend all their appointment, monitor their vital signs and
weight daily, watch what they eat, and be aware of exacerbation
symptoms. By following this alone, the patient's mortality rate
has declined slightly.
References
Chamsi-Pasha, H., & Albar, M. A. (2016). Ethical Dilemmas at
the End of Life: Islamic Perspective. Journal of Religion and
Health, 56(2), 400–410. doi: 10.1007/s10943-016-0181-3
Elkhateeb, O., & Salem, K. (2018). Patient and caregiver
education levels and readmission and mortality rates of
congestive heart failure patients. Eastern Mediterranean Health
Journal, 24(4), 345–350. doi: 10.26719/2018.24.4.345
Hadidi, S. E., Darweesh, E., Byrne, S., & Bermingham, M.
(2018). A tool for assessment of heart failure prescribing

quality: A systematic review and meta-analysis.
Pharmacoepidemiology and Drug Safety, 27(7), 685–694.
doi: 10.1002/pds.4430
Harrington, C. C. (2019). Assessing heart failure in long-term
care facilities. Journal of gerontological nursing, 45(7), 18-24.
Hart, J., & Nutt, R. (2020). Failure: A Hospital-Based
QualityImprovement Project. Nursing Economic$, 38(2),
74–85. Retrieved from https://eds-a-ebscohost
com.chamberlainuniversity.idm.oclc.org/eds/detail/detail?v
id=1&sid=ce660e9b-51a7 49f7-832a
[email protected]&bdata=JnNpdGU9ZWRzLWxpdmUmc2
NvcGU9c2l ZQ==#db=heh&AN=142593290
Harvey, P. E. (2020). Shared Medical Appointments to Improve
Self-Care Actions in the Adult Heart Failure Patient (Doctoral
dissertation, University of Missouri--Kansas City).
January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa,
J. E., Cleveland, J. C., ... & Heidenreich, P. A. (2019). 2019
AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS
guideline for the management of patients with atrial fibrillation:
a report of the American College of Cardiology/American Heart
Association Task Force on Clinical Practice Guidelines and the
Heart Rhythm Society. Journal of the American College of
Cardiology, 74(1), 104-132.
Luhr, K., Holmefur, M., Theander, K., & Eldh, A. C. (2018).
Patient participation during and after a self-management
programme in primary healthcare–The experience of patients
with chronic obstructive pulmonary disease or chronic heart
failure. Patient education and counseling, 101(6), 1137-1142.
Santesmases-Masana, R., Paz, L. G.-D., Hernández-Martínez-
Esparza, E., Kostov, B., & Navarro-Rubio, M. D. (2019).
Self-Care Practices of Primary Health Care Patients
Diagnosed with Chronic Heart Failure: ACross-Sectional
Survey. International Journal of Environmental Research and
Public Health, 16(9),1625. doi: 10.3390/ijerph16091625
Schub,, T., & Oji, O. (2018). Heart Failure: Enhancing Self-

Management. CINAHL Nursing Guide . Retrieved from
https://eds-a-ebscohost
com.chamberlainuniversity.idm.oclc.org/eds/pdfviewer/pdf
viewer?vid=7&sid=91f2548 711b-42ff [email protected]
Vellone, E., Riegel, B., & Alvaro, R. (2019). A situation-
specific theory of caregiver contributions to heart failure self-
care. Journal of Cardiovascular Nursing, 34(2), 166-173.
Wonggom, P., Nolan, P., Clark, R. A., Barry, T., Burdeniuk, C.,
Nesbitt, K., ... & Du, H. (2020). Effectiveness of an avatar
educational application for improving heart failure patients’
knowledge and self‐ care behaviors: A pragmatic randomized
controlled trial. Journal of Advanced Nursing.
Appendix
Johns Hopkins Nursing Evidence-Based Practice1. What is the
problem?
How to decrease re-hospitalization related to patients with
chronic heart failure. 2. Why is the problem important and
relevant? What would happen if it were not addressed?
Re-hospitalization is increased due to patients not monitoring
their vital signs, weight, and diet on daily basis with CHF. If
they monitored it closely, a pattern will be observed, the patient
and physician will be able to follow their condition closely, and
readmission with long hospital stay maybe decreases. If these

issues are not address, severe complications will progress and
lead to possible death. When severing symptoms start to occur,
the patient must make an appointment with their PCP. They will
not know if their symptoms are worsening unless they’re
monitoring their condition daily. 3. What is the current
practice?
The current practice for patients with CHF is to monitor their
energy level, breathing patterns, increase in coughing, heart
rate, pulse, blood pressure, and weight. Also, they are to have
frequent blood work completed.
4. How was the problem identified? (Check all that apply)
· Safety and risk-management concerns
· Quality concerns (efficiency, effectiveness, timeliness, equity,
patient-centeredness)
· Unsatisfactory patient, staff, or organizational outcomes
· Variations in practice within the setting
· Variations in practice compared to community standard
· Current practice that has not been validated
· Financial concerns 5. What are the PICO components?
P – (Patient, population, or problem) Patients of all ages and
genders
I – (Intervention) Blood pressure medications, diuretics,
education on H.F., diagnostic test such as an ECHO, chest x-
ray, EKG, ultrasound, vital signs, oxygen if needed
C – (Comparison with other interventions, if foreground
question) Beginning of condition and hospital stay
O – (Outcomes are qualitative or quantitative measures to
determine the success of change) Decrease hospital readmission
and length of stay, keeps the patient and physician updated with
condition 6. Initial EBP question ❑ Background ❑
Foreground
How does the use of in-home monitoring for CHF impact re-
hospitalization rates?

How will the patient be able to monitor their CHF at home daily
with understanding?
Does the patient have full knowledge on how to monitor their
CHF at home and when to contact their provider?
7. List possible search terms, databases to search, and search
strategies.
CHF home monitoring, CHF, heart failure management, patient
education, Chamberlain Library, GOOGLE
8. What evidence must be gathered? (Check all that apply)
· Publications (e.g., EBSCOHost, PubMed, CINAHL, Embase)
· Standards (regulatory, professional, community)
· Guidelines
· ORGANIZATIONAL DATA (E.G., Q.I., FINANCIAL DATA,
LOCAL CLINICAL EXPERTISE, PATIENT/FAMILY
PREFERENCES)
· Position statements9. Revised EBP question
(Revisions in the EBP question may not be evident until after
the initial evidence review; the revision can be in the
background question or a change from the background to a
foreground question)
readmission be decreased with adequate education and home
(C), during the course of the patient’s condition (O).
10. Outcome measurement plan
What will we measure?
(structure, process, outcome measure)
How will we measure it?

(metrics are expressed as rate or percent)
How often will we measure it?
(frequency)
Where will we obtain the data?
Who will collect the data?
To whom will we report the data?
Outcome measurement with daily vitals, weight, and diet
tracking
Measure by daily logs of vitals, weight, and meals weekly
Daily checks, 3 times a day
From the patient home logs
The patient
The patient will report daily or weekly logs to the ANP with
significant findings and changes immediately
Running head: STATE OF SCIENCE QUALITY
IMPROVEMENT 1
Johns Hopkins Nursing Evidence-Based Practice
Appendix B: Question Development Tool

STATE OF SCIENCE QUALITY IMPROVEMENT
14
Additionally, submit a 2 paragraph minimum (4-5 sentences per
paragraph) narrative that describes one ethical dilemma or
ethical consideration that is connected to your PICO
question. In order to include this ethical component, review and
critique the articles in your review of literature.
When dealing with patients that have CHF, treatment, and
overall care can be challenging at times. With the increase in
population size (primarily the aging), unhealthy lifestyles, and
unorganized healthcare, ethical dilemmas are impossible not to
see. For instance, many primary care providers lately only focus
on the textbook guidelines that are given instead of focusing on
the patient's unique condition. Unfortunately, treatment is based
on how the disease can be handled in the long run instead of
what medicine is good for what is happening now. Furthermore,
the treatment of choice needs to be viewed as being beneficial
and can the patient complies. Is the patient able to monitor their
condition from home? Are they mentally and physically capable
of handling equipment, writing down results, and understand
what to report?
Chronic heart failure is a condition that shortens the life of
those affected. Starting from the time of diagnosis, many things
need to be considered and treatment plans. Finding the right
cardiologist and being able to follow through with the plans
provided is a must. Also, as life starts to worsen, having an
advanced directive and end-of-life details are very important.
When making end-of-life decisions, primary care providers and
cardiologists must acknowledge the patient's religion, age, and
support system. For instance, those of Islamic faith do not
believe in continuing life on life supportive equipment, and
those that are terminally ill must die naturally (Chamsi-Pasha &
Albar, 2016). So as of now, the overall dilemma would be on

the proper treatment plan that is currently beneficial for the
patient.
Running head: STATE
OF SCIENCE QUALITY IMPROVEMENT
1
State
of the Science Quality Improvement
Name
Institutions
Date

Laboratory assignment
The following questions are from two exercises
(dilutions/pipetting and counting bacteria) that you
read/studied. As reference materials, read lab manual, lab
exercise PPts and/or study guides and answer questions given
below fully/completely in the spaces provided as instructed.
Please submit assignment before or on the due date. Hand
written answers are not acceptable, except calculations.
You may submit assignment as an attachment to an email.
Alternatively, you may scan assignment or take a photo it and
submit as an attachment to an email.
Part One: Pipetting and Dilutions
A. 1. Objectives of this exercise – briefly describe the
objectives of this exercise in your own English (refer to lab
manual or PPt)
A. 2. Define Solute:
A. 3. Define Solvent:
A. 4. Define dilution:
A. 5. Define solution:
B: Pipetting and Dilutions
B. 1. For each set of dilutions in figure below, calculate the
amount of colored substance (dilutions) in the last test tube of

each set. Show calculation steps and results in the spaces
provided.
B. 2. For questions B. 2. 1—B. 2. 3 in lab manual, firstwrite
down each question and then give the corresponding answers.
B. 2.1. What is the “meniscus”?
B. 2. 2. If you transfer 0.1ml of a sample into a 99.9ml saline
blank, what is the dilution
factor (show calculation steps)?
B. 2. 3. How much fluid is IN the pipette below?
_________________________.
B. 3. For the following 3 questions (B. 3. 1 – B. 3. 3) in lab
manual, first determine:
· The number of countable colonies (colony forming units,
CFUs) that fall within the range of 30-300.
· The dilution factor that gave the count (example: 10-4 or
1/104)
· The amount of diluted sample plated/added (in ml) to each
plate that gave the corresponding count.
· Then calculate the number of bacteria in 1 ml of original
(undiluted) sample (solid or liquid) using formula given in
manual or PPt. Show calculation steps.
Note: If sample is solid (example: hamburger meat), report
count as CFUs per gram of meat. If sample is liquid (example:
milk), report count as CFUs per ml of milk.
B. 3. 1.
B. 3. 2. B. 3. 3.

Part two: Counting (enumeration) bacteria
2. 1. Objectives of this exercise - briefly describe the objectives
in your own English
(see lab manual)
2. 2. What is viable plate count?
2. 3. What do you use to determine the number of bacteria in
suspension by the
turbidimetric method?
2. 4. For questions 2. 4. 1 -- 2. 4. 6 inlab manual, first write
down each question and then give the corresponding answers.
2. 4. 1. Data collection (Insert data table here from PPt)
2. 4. 2. Why do you have to do a standard plate count when
running turbidity values the
first time?
2. 4. 3. If you have a graph for E. coli, can the same graph also
be used for another
bacterium, like Staph?
2. 4. 4. How is “transmission” different from “absorbance”?
2. 4. 5. Give the formula for calculating the number of bacteria
in 1 ml or 1 gram original
sample (example: cheese or fruit juice). (Show calculation
steps.
2. 4. 6. Using the formula in above question, calculate the

bacterial count per milliliter
of E. coli suspension in the original culture tube.
Important: To complete data table (2. 4. 1), enter count (2. 4. 6,
above)
into y-axis column (first for original E. coli) in data table
(question # 2.
4.1.) given in PPt. Then divide count by 2 (or multiply count by
½) to
enter
count for each corresponding absorbance value under x-axis
column.
Finally enter zero (0) for both x- and y-axis columns.
2. 4. 7. Finally, using Excel graphic software, plot a standard
curve using data from step 2. 4. 1, above. When entering your
data in Excel graphic, start with the zero values (X-axis=0 and
Y-axis=0) and finish with the highest values. Use absorbance
column values for X-axis and the number of E. coli calculated
for Y-axis. To plot the graph, follow the steps given in your
manual. Please include curve/graph with the rest of report and
submit before or due date. Be warned that no assignment is
accepted after due date.
Due date: Friday, June 19 @midnight
PAGE
1
Date:
EBP Question:
Article Number
Author and Date
Evidence Type
Sample, Sample Size, Setting
Findings That Help Answer the EBP Question
Observable Measures
Limitations

Evidence Level, Quality
· N/A
· N/A
· N/A

· N/A
Attach a reference list with full citations of articles reviewed
for this EBP question.
Date:
EBP Question:
Article Number
Author and Date
Evidence Type
Sample, Sample Size, Setting
Observable Measures
Limitations
Evidence Level, Quality
· N/A

· N/A
· N/A
Appendix G
Individual Evidence Summary Tool
Appendix G
Individual Evidence Summary Tool
3

Directions for Use of the Individual Evidence Summary Tool
Purpose
This form is used to document the results of evidence appraisal
in preparation for evidence synthesis. The form provides the
EBP team with documentation of the sources of evidence used,
the year the evidence was published or otherwise
communicated, the information gathered from each evidence
source that helps the team answer the EBP question, and the
level and quality of each source of evidence.
Article Number
Assign a number to each reviewed source of evidence. This
organizes the individual evidence summary and provides an
easy way to reference articles.
Author and Date
Indicate the last name of the first author or the evidence source
and the publication/communication date. List both
author/evidence source and date.
Evidence Type
Indicate the type of evidence reviewed (e.g., RCT, meta-
analysis, mixed methods, quaLitative, systematic review, case
study, narrative literature review).
Sample, Sample Size, and Setting
Provide a quick view of the population, number of participants,
and study location.
Although the reviewer may find many points of interest, list
only findings that directly apply to the EBP question.
Observable Measures
QuaNtitative measures or variables are used to answer a
research question, test a hypothesis, describe characteristics, or
determine the effect, impact, or influence. QuaLitative evidence
uses cases, context, opinions, experiences, and thoughts to
represent the phenomenon of study.
Limitations
Include information that may or may not be within the text of

the article regarding drawbacks of the piece of evidence. The
evidence may list limitations, or it may be evident to you, as
you review the evidence, that an important point is missed or
the sample does not apply to the population of interest.
Evidence Level and Quality
Using information from the individual appraisal tools, transfer
the evidence level and quality rating into this column.
State of the Science Quality ImprovementRachael Tenner
Chamberlain University
NUR505NP
Dr. Bethel
June 14, 2015
Abstract

The condition of heart failure (HF), sometimes also referred to
as congestive heart failure (CHF), is recognized as an acute life -
threatening disease that extensively affects millions of
American citizens annually. The condition of chronic heart
failure results when the heart is incapable of sufficiently
pumping blood throughout the body to adequately reach the
lung and tissues due to the weakening of heart muscles (Januar y
et al., 2019). Several conditions overwork the heart, such as
coronary artery diseases, as well as hypertension, diabetes, and
renal diseases that lead to acute and chronic heart failure in the
body systems. It is imperative to prevent, control, and manage
this crucial condition as health care expenditures have become a
significant focus for the country, especially with readmission
rates. The patient must be able to control the earlier stated
diseases, diabetes, and obesity in home-based care settings and
with their primary healthcare providers. According to
Santesmases-Masana et al. (2019), “Primary health care or
planned care has been shown to reduce heart failure re-
hospitalizations and maintain the patient quality of life.” With
this known knowledge, it is important to continue care at home
with the partnership of one’s primary care provider to monitor
and detect worsening of their condition sooner rather than later
with evidence-based treatment practices. There are many
evidence-based treatments for chronic heart failure that includes
monitoring of vital signs, weight, and diet along with
medications. In this paper, chronic heart failure, problem
discussion, PICO question, and theoretical framework will be
presented.
Problem Discussion
Increase hospital readmission and worsening chronic heart
failure complications are correlated to lack of following of a
primary care provider directions and inefficient home
monitoring of vital signs, weight, diet, energy levels, and
breathing patterns by the patient. There are several evidence-
based practices and comprehensive guidelines for chronic heart
failure treatment with side effects of some medications

regarding individual races. For instance, losartan has little to
weak impact on African Americans. Furthermore, according to
Hadidi et al. (2018), "It has been shown that under prescribing
of evidence‐ based therapies is associated with worsening heart
failure and higher rates of heart failure hospital admissions and
mortality." Unfortunately, as the rate of chronic heart failure
increases due to the aging population's increase, home
monitoring will decline due to mental, physical, and financial
instability and lack of support.
Home monitoring is an essential part of patients with chronic
heart failure. However, some patients cannot mentally process
the importance of taking their vital signs (most importantly,
blood pressure) a few times a day and writing it down. With the
aging population, dementia may start to set in, and they will
forget to take their medication and monitor their blood pressure.
They may remember to take their medication but forget to take
their vitals, and their blood pressure could already below, which
will lead to further complications. The patient may also be
physically incapable of using medical equipment if a support
person is not present. Other limitations may include financially
with the ability to obtain a sphygmomanometer, thermometer,
pulse oximeter, or transportation to their primary care provider.
Also, their finances may not allow them to purchase healthy
foods (more expensive) over non-healthy foods (less expensive)
on a routine basis.
Since chronic heart failure requires significant monitoring and
treatments, proper health insurance is necessary for continued
adequate care. Lack of health coverage will lead to inadequate
healthcare due to high costs. This unfortunate event of not
having insurance will lead to an increase in emergency room
visits and hospital admissions for treatments, interventions, and
management. Lack of chronic heart failure monitoring will thus
lead to further complications and increase hospital stay.
According to Hart and Nutt (2020), "Heart failure (HF)
contributes to the highest frequency of 30-day hospital
readmissions out of all causes, raising the already significant

risk for adverse outcomes and costs." Overall, heart failure is
proliferating, with an equally increasing mortality rate. Without
proper, patient-specific education with return clarification, new
monitoring tools, and technology, hospital readmission will
continue to rise. Ongoing, updated, and frequent training is
required for patients with chronic heart failure to increase home
monitoring and decrease hospitalization.
The aim of decreasing hospital readmission from exacerbation
of chronic heart failure will require the collaboration of
everyone involved with patient care. Education is the first and
most crucial part, starting with the medical team. When
emphasizing self-care and chronic heart failure management
through effective teaching and communication, combined with
follow-ups, hospital readmissions will be minimized (Hart and
Nutt, 2020). Ensuring the patient understands and accepts their
current condition is a must for them to be compliant at home
with the required treatment regimen. Next, make sure they can
obtain specific medical equipment at home to assess all their
vital signs, most importantly, their blood pressure. Educate
them on the normal ranges so abnormal ranges can be reported.
Please make sure they can manipulate the equipment and log all
their results. Lastly, make sure the patient gets started on the
proper diet and able to assess their weight daily. Along with
education, multidisciplinary outpatient programs will be very
beneficial to the patient, so their knowledge of chronic heart
failure and self-care will be sustainable and carried out
(Harvey, 2020).
PICO Question and Review of Literature
monitoring (I), after their diagnosis and initial
hospitalization (C), during the course of the patient’s
condition (O).
For this quality improvement paper, this author used
Chamberlain University’s online Library to access many

databases such as EBSCO Information Services, CINAHL, Pro-
Quest, and Cochrane. Also, the American Heart Association
website was used from the Google search engine. Many search
terms were used that were relevant to the topic: heart failure,
chronic heart failure, stakeholders, insurance management for
heart failure, heart failure education, and heart failure
monitoring. (See The John Hopkins Question Development Tool
in the appendix).
Heart failure is briskly rising in the United States. Still , patients
that closely monitor their condition at home leads to cost-
effective care and reduce hospital admissions from adequately
and timely patient education provided by their provider (Schub
& Oji, 2018). The American Heart Association offers a
considerable amount of information for heart failure and the
importance of patient education. During the initial
hospitalization and diagnosis of heart failure, learning should
be initiated immediately due to the critical role it plays with
chronic heart failure management (January et al., 2019). As the
population grows, chronic heart failure increases within the
aging population due to deterioration of the heart muscle. A
slower progression of the disease can occur with proper self-
care (Wonggom et al., 2020). However, Elkhateeb and Salem
(2018) did research that showed that the correlation between
family support and patient education did not correlate with
either hospital readmissions or mortality rates. Luhr et al.,
(2018) researched was done on elderly education and concluded
that the elderly population did not have a more significant
outcome of quality of life when given proper training by their
primary care provider, compared to those with routine care.
However, Hart and Nutt (2020) stated, “As little as one 60-
minute, targeted education session with nurses trained in heart
failure is effective at improving disease knowledge and self-
care and reducing hospital readmissions.”
Quality Change Plan
The theoretical framework that will be used for this quality

improvement project is the Situation-Specific Theory of Heart
Failure Self-care that was published in 2008, which shows how
patients with chronic heart failure care for themselves and
manages their condition (Vellone et al., 2019). According to
Vellone et al. (2019), “Self-care was defined as a naturalistic
decision-making process involving the choice of behaviors that
maintain physiologic stability (maintenance) and the response to
symptoms when they occur (management).” With this theory,
there are three areas of focus on self-care maintenance,
symptom perception, and symptom management that help the
provider assess the patient’s mental condition (Hart and Nutt,
2020). This theory has been previously used and can be used
and applied to this improvement project on chronic heart
failure. This is accomplished by describing the patient’s current
situation with chronic heart failure, showing how the elements
are congruent to each other, and predicting the future/outcomes;
however, further research is needed (Vellone et al., 2019).
The condition of chronic heart failure is a concerning factor for
many stakeholders. Those that are affected by chronic heart
failure along with the patient (primary stakeholder) are their
support system, health organizations, insurance companies,
primary care providers, and nurses. Besides the patient (with
full mental capacity), the support person, nurses, and primary
care provider are best to detect changes in early signs of chronic
heart failure exacerbation of non-specific symptoms
(Harrington, 2019). The primary care provider needs to update
and make patient screenings more patient-specific and more
closely supervised to ensure understanding and acceptance
(Santesmases-Masana et al., 2019). All stakeholders' full
knowledge and cooperation with the recommended treatment
plan for patients with chronic heart failure are required for a
sustainable and effective outcome of limiting hospital
readmission. Furthermore, the primary care providers must
make sure they are prescribing the right treatment regime for
the patient because that could increase their mortality rate.
Guidelines recommend a multidisciplinary approach to HF.

Research indicates that various team members to provide
knowledge on an individualized basis is beneficial. The use of
mobile apps creates significantly improves patient compliance
obtained for the management of HF. However, more research is
indicated. Interventions are known to reduce rehospitalization
rates by 44%, with improved quality of life scores and a
reduction in overall costs. The statistical analyses were
conducted using GraphPad Prism_7 software (GraphPad
Software, La Jolla, CA, USA). Extended variables were given as
a calculation pattern ± standard deviation/standard error of the
mean and definitive variables as numbers and percentages.
Changes amongst clinical or device‐ related parameters at the
three-time points were evaluated by paired t-test (α = 0.05). To
assess the relationship between traditional clinical settings and
mHealth data, the Pearson product-moment interrelationship
coefficient (r ) was determined. The measurement certainty of
the smart devices compared with precedent amounts was
evaluated by appraising the average percentage of a flaw and
the mean infinite percentage inaccuracy.
Conclusion
Chronic heart failure is a condition that is ever-increasing in
rates globally, with increase hospital re-admissions and
mortality rates, especially among the older population. To
reduce the advancement of this condition and have better
control, collectively, the patient must have sufficient full
knowledge of self-care and education on chronic heart failure
(Wonggom et al., 2020). Many factors play a vital role in
chronic heart failure monitoring and maintenance. The patient
must remember to attend all their appointment, monitor their
vital signs and weight daily, watch what they eat, and be aware
of exacerbation symptoms. By following this alone, the
patient’s mortality rate has declined slightly.
References
Chamsi-Pasha, H., & Albar, M. A. (2016). Ethical Dilemmas at

the End of Life: Islamic Perspective. Journal of Religion and
Health, 56(2), 400–410. doi: 10.1007/s10943-016-0181-3
Elkhateeb, O., & Salem, K. (2018). Patient and caregiver
education levels and readmission and mortality rates of
congestive heart failure patients. Eastern Mediterranean Health
Journal, 24(4), 345–350. doi: 10.26719/2018.24.4.345
Hadidi, S. E., Darweesh, E., Byrne, S., & Bermingham, M.
(2018). A tool for assessment of heart failure prescribing
quality: A systematic review and meta-analysis.
Pharmacoepidemiology and Drug Safety, 27(7), 685–694.
doi: 10.1002/pds.4430
Harrington, C. C. (2019). Assessing heart failure in long-term
care facilities. Journal of gerontological nursing, 45(7), 18-24.
Hart, J., & Nutt, R. (2020). Failure: A Hospital-Based
QualityImprovement Project. Nursing Economic$, 38(2),
74–85. Retrieved from https://eds-a-ebscohost
com.chamberlainuniversity.idm.oclc.org/eds/detail/detail?v
id=1&sid=ce660e9b-51a7 49f7-832a
[email protected]&bdata=JnNpdGU9ZWRzLWxpdmUmc2
NvcGU9c2l ZQ==#db=heh&AN=142593290
Harvey, P. E. (2020). Shared Medical Appointments to Improve
Self-Care Actions in the Adult Heart Failure Patient (Doctoral
dissertation, University of Missouri--Kansas City).
January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa,
J. E., Cleveland, J. C., ... & Heidenreich, P. A. (2019). 2019
AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS
guideline for the management of patients with atrial fibrillation:
a report of the American College of Cardiology/America n Heart
Association Task Force on Clinical Practice Guidelines and the
Heart Rhythm Society. Journal of the American College of
Cardiology, 74(1), 104-132.
Luhr, K., Holmefur, M., Theander, K., & Eldh, A. C. (2018).
Patient participation during and after a self-management
programme in primary healthcare–The experience of patients

with chronic obstructive pulmonary disease or chronic heart
failure. Patient education and counseling, 101(6), 1137-1142.
Santesmases-Masana, R., Paz, L. G.-D., Hernández-Martínez-
Esparza, E., Kostov, B., & Navarro-Rubio, M. D. (2019).
Self-Care Practices of Primary Health Care Patients
Diagnosed with Chronic Heart Failure: ACross-Sectional
Survey. International Journal of Environmental Research and
Public Health, 16(9),1625. doi: 10.3390/ijerph16091625
Schub,, T., & Oji, O. (2018). Heart Failure: Enhancing Self-
Management. CINAHL Nursing Guide . Retrieved from
https://eds-a-ebscohost
com.chamberlainuniversity.idm.oclc.org/eds/pdfviewer/pdf
viewer?vid=7&sid=91f2548 711b-42ff [email protected]
Vellone, E., Riegel, B., & Alvaro, R. (2019). A situation-
specific theory of caregiver contributions to heart failure self-
care. Journal of Cardiovascular Nursing, 34(2), 166-173.
Wonggom, P., Nolan, P., Clark, R. A., Barry, T., Burdeniuk, C.,
Nesbitt, K., ... & Du, H. (2020). Effectiveness of an avatar
educational application for improving heart failure patients’
knowledge and self‐ care behaviors: A pragmatic randomized
controlled trial. Journal of Advanced Nursing.
Appendix
Johns Hopkins Nursing Evidence-Based Practice1. What is the
problem?
How to decrease re-hospitalization related to patients with
chronic heart failure. 2. Why is the problem important and
relevant? What would happen if it were not addressed?
Re-hospitalization is increased due to patients not monitoring
their vital signs, weight, and diet on daily basis with CHF. If
they monitored it closely, a pattern will be observed, the patient
and physician will be able to follow their condition closely, and
readmission with long hospital stay maybe decreases. If these
issues are not address, severe complications will progress and

lead to possible death. When severing symptoms start to occur,
the patient must make an appointment with their PCP. They will
not know if their symptoms are worsening unless they’re
monitoring their condition daily. 3. What is the current
practice?
The current practice for patients with CHF is to monitor their
energy level, breathing patterns, increase in coughing, heart
rate, pulse, blood pressure, and weight. Also, they are to have
frequent blood work completed.
4. How was the problem identified? (Check all that apply)
· Safety and risk-management concerns
· Quality concerns (efficiency, effectiveness, timeliness, equity,
patient-centeredness)
· Unsatisfactory patient, staff, or organizational outcomes
· Variations in practice within the setting
· Variations in practice compared to community standard
· Current practice that has not been validated
· Financial concerns 5. What are the PICO components?
P – (Patient, population, or problem) Patients of all ages and
genders
I – (Intervention) Blood pressure medications, diuretics,
education on HF, diagnostic test such as an ECHO, chest x-ray,
EKG, ultrasound, vital signs, oxygen if needed
C – (Comparison with other interventions, if foreground
question) Beginning of condition and hospital stay
O – (Outcomes are qualitative or quantitative measures to
determine the success of change) Decrease hospital readmission
and length of stay, keeps the patient and physician updated with
condition 6. Initial EBP question ❑ Background ❑
Foreground
How does the use of in-home monitoring for CHF impact re-
hospitalization rates?
How will the patient be able to monitor their CHF at home daily

with understanding?
Does the patient have full knowledge on how to monitor their
CHF at home and when to contact their provider?
Running head: STATE OF SCIENCE QUALITY
IMPROVEMENT 1
Appendix B: Question Development Tool
STATE OF SCIENCE QUALITY IMPROVEMENT
2
7. List possible search terms, databases to search, and search
strategies.
CHF home monitoring, CHF, heart failure management, patient
education, Chamberlain Library, GOOGLE
8. What evidence must be gathered? (Check all that apply)
· Publications (e.g., EBSCOHost, PubMed, CINAHL, Embase)
· Standards (regulatory, professional, community)
· Guidelines
· Organizational data (e.g., QI, financial data, local clinical
expertise, patient/family preferences)
· Position statements9. Revised EBP question
(Revisions in the EBP question may not be evident until after
the initial evidence review; the revision can be in the
background question or a change from the background to a

foreground question)
(C), during the course of the patient’s condition (O).
10. Outcome measurement plan
What will we measure?
(structure, process, outcome measure)
How will we measure it?
(metrics are expressed as rate or percent)
How often will we measure it?
(frequency)
Where will we obtain the data?
Who will collect the data?
To whom will we report the data?
Outcome measurement with daily vitals, weight, and diet
tracking
Measure by daily logs of vitals, weight, and meals weekly
Daily checks, 3 times a day
From the patient home logs
The patient
The patient will report daily or weekly logs to the ANP with
significant findings and changes immediately

Ethical Dilemma
When dealing with patients that have CHF, treatment, and
overall care can be challenging at times. With the increase in
population size (primarily the aging), unhealthy lifestyles, and
unorganized healthcare, ethical dilemmas are impossible not to
see. For instance, many primary care providers focus mainly on
textbook guidelines that are provided instead of delivering care
based on the patient's unique conditions. Heightened concern
should be placed on how the disease can be managed in the long
run, as opposed to only managing acute exacerbations.
Furthermore, the treatment options need to be viewed as being
beneficial to enhancing one's life to increase patient
compliance. Other ethical considerations and questions to ask
include; Is the patient able to monitor their condition from
home? Are they mentally and physically capable of handling
equipment, writing down results and provider recommendations,
and understand what to report?
Chronic heart failure is a condition that shortens the life of
those affected. Starting from the initial diagnosis, many things
need to be considered during the care process. Individuals must
find the right care provider and be able to follow through with
the managed care plans provided.
With HF disease progression, there are many advantages to
having an advanced directive and end-of-life. When making
end-of-life decisions, primary care providers and must
acknowledge the patient's religion, age, and support system. For
instance, those of Islamic faith do not believe in continuing life
on life supportive equipment, and those that are terminally ill
must die naturally (Chamsi-Pasha & Albar, 2016). Ethical
considerations should be placed on ensuring that the patient's
culture and belief systems are incorporated with their plan of
care.

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