Obiettivi, organizzazione e attività di un Ambulatorio Infermieristico Cardiologico di Continuità Assistenziale

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BACKGROUND: Cardiovascular diseases are the first cause of death worldwide. In the last decades, therapeutic advances have determined an increase in survival rates, with a subsequent rise in the number of elderly people suffering from chronic cardiovascular diseases and associated comorbidities requiring comprehensive, team-based multidisciplinary care. The aim of this study is to describe the organization, purposes and activities of a nurse-led cardiology clinic. METHODS: Between November 1, 2009 and October 31, 2014, the nurse-led clinics located within our Cardiology Outpatient Center provided care to 2081 out of 26 057 patients (8%) with complex healthcare needs, high cardiovascular risk and/or specific therapeutic indications or needs for reassessment; 1875 of these patients received nurse-led interventions: 451 (21.7%) in Chronic Heart Disease (CHD) care; 402 (19.3%) in Heart Failure (HF) care; 1022 (49.1%) at the Oral Anticoagulant Therapy (OAT) care, while 206 patients (9.9%) underwent Nurse Triage. Nursing assessment includes a clinical multidimensional analysis, with identification of relevant health issues and planning of a nursing intervention (education, intensified monitoring, and support to therapy) shared with the cardiologist in a joint report. RESULTS: The clinical characteristics and the social care needs of the patients who received nurse-led care were extremely heterogeneous. Patients with heart failure were the oldest (79 years), most severe (58.2% hospitalized last year), with Charlson index ≥3% (82.8 %); 72.4% were taking ≥7 drugs daily. The majority of them had medium-to-low education levels and more frequently lived alone, with disabilities, inadequate self-monitoring, and self-care behaviors. Patients on anticoagulant therapy were younger (71 years), in 75.9% of cases with atrial fibrillation, most frequently assisted by a caregiver and without functional limitations. The patients of these two nurse-led clinics (HF and OAT) were those who came most frequently after hospital discharge, presented mainly clinical instability and problems of adherence to the therapeutic programs, and needed in most cases a therapeutic intervention associated with an intensification of clinical/behavioral monitoring. CONCLUSIONS: Nursing assessment supports the specialist's intervention by intensifying clinical surveillance and therapeutic intervention in the most complex real-world patients. It provides information to complete the cardiological assessment and is essential to better understand patients' health and social care needs, and to suggest and coordinate a tailor-made plan.

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