Congestive Heart Failure

1. Congestive Heart Failure Making the most of Your Discharge Teaching Tania Randell, RN-BC, BSN

2. Objectives • be able to explain the importance of proper Congestive Heart Failure (CHF) discharge teaching • be able to state the 5 most important elements of CHF discharge teaching • identify 3 challenges for educating the CHF patient • identify 3 solutions to the challenges of educating CHF patients • be able to apply what you’ve learned to a case-study scenario

3. Background of the disease Why is teaching so important?

4. What is CHF? • Weakened myocardium • Reduced ability to pump blood through the body • Back-up of blood/fluid into lungs = pulmonary congestion • Decreased perfusion to other organs • Oxygen- Supply and Demand • Ejection Fraction (LVEF) • Normal > 50% • Heart failure < 40%

5. What causes CHF? • MI- ischemia of myocardium • Htn • DM • Congenital • Valve disease • Family history

6. Types of Heart Failure Systolic Dysfunction (reduced EF)- contractility • Ischemic • Dilated CM (big and floppy) • Ventricular hypertrophy (too much to fight against)

7. Dilated Cardiomyopathy

8. Types of Heart Failure Diastolic Dysfunction (Normal EF)- filling • Ventricular Hypertrophy (long-standing Htn) • Increased stiffness of Ventricles (can’t relax) • Restrictive (amyloid, sarcoid) • Valve stenosis (mitral or tricuspid) • Pericardial disease

9. Hypertrophic Obstructive CM

10. Symptoms • Dyspnea- on exertion and at night (L) • SOB (L) • Fatigue (R) • Swelling of lower extremities (R) • Lack of appetite with advanced HF • Less common symptoms (20%) • Chest pain • Palpitations

11. Goals of Therapy • Reduce Signs and Symptoms • Maintain the patient’s lifestyle (quality of life) • Prolong life

12. Around 5.8 million people in the United States have heart failure… HEART FAILURE FACTS….

13. About 1 in 5 people (20%) who have heart failure die within one year from diagnosis… HEART FAILURE FACTS….

14. The mortality rate is 40% - 50% over 5 years HEART FAILURE FACTS….

15. Readmissions can cost between $6,000 and $10,000 each HEART FAILURE FACTS….

16. Avoidable readmissions of patients within 30 days cost Medicare > $17 billion yearly HEART FAILURE FACTS….

17. the direct and indirect cost of heart failure estimated at $37 billion in the U.S. for 2009 HEART FAILURE FACTS….

18. Public Knowledge • Hospital data is public knowledge • USA Today website- Morbidity and readmission rates • Medicare publicly reports readmission rates • Healthcare Reform passed in March 2010, measures will be taken to reduce Medicare readmission rates • Starting in 2012, Medicare will cut reimbursement to hospitals with high 30 day readmission rates.

19. National objectives for Joint Commission • The Joint Commission has 11 core measure sets (including HF) • HF Core Measure Set- 4 elements • discharge instructions is the first one. • 6 elements to cover for discharge instruction

20. If you were the joint commission, what would you require?

21. JC Core Measure Set • HF discharge instruction should Include 6 elements: • 1.activity level • 2.diet • 3.discharge medications • 4.follow-up appointment • 5.weight monitoring • 6.what to do if symptoms worsen

22. Outcomes- our impact • Beta-blockers‡ I 33% mortality reduction • ACE inhibitors/ARBs I 20% mortality reduction • Smoking cessation II-2 Improved quality of life • Discharge education I 10% mortality reduction, 25% reduction in readmission • Level I- from randomized, controlled trials • Level II- observational or retrospective studies

23. Why do nurses really care about CHF teaching? • Patients should be empowered to take part in their care • Knowledge of their own disease gives a better feeling of control • Increased compliance with regimen • Better quality of life

24. Most important topics to cover with your patient The Top 5

25. 5. Diet • Nutrition Consult during stay- food labels • 1 alcoholic drink/day • Sodium- 3 g of salt per day • (3 g salt ≈ 1/2 tsp salt ≈ 1200 mg sodium) • Prepared foods • Salt substitute • Water restriction • 1.5–2 Liters each day • Why?

26. 4. Rest & Activity • Stress test first • Listen to your body • Activity 2-3x/wk 30-40’ • (adjust for NYHA class IV HF) • Daily weights- fluid overload • Report 2 lb gain in 1-2 days and 5 lb gain in 1 week

27. 3. Smoking Cessation • Tobacco Treatment- JC • They need all the reinforcement they can get! • Make sure provider has a plan in place • Support and medication • Emphasize quality of life

28. Why Smoking & Alcohol? • Smoking contributes to CAD • ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult • Control of Conditions That May Cause Cardiac Injury: • “Many therapeutic and recreational agents can exert important cardiotoxic effects, and patients should be strongly advised about the hazards of smoking, as well as the use of alcohol, cocaine, amphetamines, and other illicit drugs”

29. 2. Medication compliance • Avoid NSAIDS: trigger exacerbations • Diuretics: reduce workload on heart (careful with BP & electrolytes) • ACE & ARB’s: reduce mortality • B-blockers: reduce workload & mortality (don’t stop abruptly)

30. 1.Reporting of Symptoms • Cardinal rule: • Report 2 lb gain in 1-2 days and 5 lb gain in 1 week • Notice increases in SOB & swelling • Don’t ignore a change in the way you feel • Who to call when • Importance of follow-up appointments (review date of first one, reinforce importance)

31. Reaching your patient is not always easy What will stand in my way?

32. Level of education • Illiteracy • in 2003, 16% of Baltimore was considered illiterate- Literacy Council website • People who read at low levels are 1.5 to 3 times more likely to have adverse health outcomes compared with people who read at higher levels • Health literacy - medication recall, adhere to treatment plan • HL = Re-hospitalization rates • Assessment tools available • Well educated patients • Encourage them to ask questions

33. Overwhelming hospital visit • Emotional state • New diagnosis • Flurry of providers and information • Too much for patient to absorb

34. Distractions • Immediate discomfort or pain • Distraction by hospital environment • Roommate • Providers on rounds/Noisy hallways • Their own family members

35. Ability to learn & Retention • Age of the patient • Hard of hearing • Poor vision • Dementia

36. Making teaching easy & more effective How can I get through to them?

37. Assess learning level, target teaching • You will already know your patient • Clues to illiteracy- Excuses from patient • Target the paperwork (preferred language) • Educated patients- more detail • Include family or caregivers • Give many chances for questions

38. minimize distractions • Create a great learning environment • Quiet, bright, a table • Make sure your patient is comfortable • Address physical needs- pain/discomfort • Leave enough time • Make yourself comfortable too

39. The overwhelmed patient • Wait for the best time • Address emotional needs first • Address outstanding questions • give encouragement and explain “failure” doesn’t mean the end of their life

40. maximize retention • Include family members/caregivers • Provide written material • Detail when they ask • Compensate for deficits- HOH, vision

41. A case study for practice Putting it all together

42. Mrs.Dorothy Framingham PMH: • 70 y/o female • CHF, EF 30% (diagnosed 6 months ago) • Rheumatoid Arthritis • Current smoker (25 pack-year history) • HOH Left ear

43. Mrs.Dorothy Framingham HPI: Several recent admissions to community hospital for fluid overload. Current admission through ED, p/w respiratory distress, O2 sat mid 70’s, HR 130’s. Transferred to Cardiac Progressive Care Unit, diuresed, awaiting discharge.

44. References • http://circ.ahajournals.org/content/112/12/1825.ful • http://www.ajc.com/news/atlanta/hospitals-work-to-lower-1205289.html • http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm • Ciccone, M.M., Aquilino, A., Cortese, F., Scicchitano, P., Sassara, M., Mola, E., Rollo, R., Caldarola, P., Giorgino, F., Pomo, V., Bux, F. (2010). Feasibility and effectiveness of a disease and care management model in the primary health care system for patients with heart failure and diabetes (Project Leonardo). Vascular Health and Risk Management, 6: 297–305. • Evangelista, L.S., Rasmusson, K.D., Laramee, A.S., Barr, J., Ammon, S.E., Dunbar, S. Ziesche, S., Patterson, J.H., Yancy, C.W. (2010). Health Literacy and the Patient With Heart Failure—Implications for Patient Care and Research: A Consensus Statement of the Heart Failure Society of America. Journal of Cardiac Failure, 16(1), 9–16. • Gruszczynski, A.B., Schuster, B., Regier, L., Jensen, B. (2010). Targeting success in heart failure: Evidence-based management. Canadian Family Physician, 56(12), 1313–1317

45. References • http://www.hfsa.org/default.asp • Masica, A.L., Richter, K.M., Convery, P. Haydar, Z. (2009). Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Proceedings (Baylor University Medical Center), 22(2), 103–111. • Song, E.K., Moser, D.K., Rayens, M.K., Lennie, T.A. (2010). Symptom clusters predict event-free survival in patients with heart failure.Journal of Cardiovascular Nursing, 25(4), 284–291. • http://www.hospitalmedicine.org/AM/pdf/advocacy/CRS_Readmissions_Report.pdf • Welsh, D., Marcinek, R., Abshire, D., Lennie, T., Biddle, M., Bentley, B., Moser, D. (2010). Theory-based Low-Sodium Diet Education for Heart Failure Patients. Home Healthc Nurse, 28(7), 432–443.