Heart Failure Clinical Process Guideline

1. Heart Failure Clinical Process Guideline Deborah Ayers, RN, MSN Quality Improvement Nurse Consultant

2. General Information • “Optional” Best Practice Tool • Effective date for usage • Electronic copies of the tool are available on the website • http://michigan.gov/bhs; click “Best Practice Information & Guidelines”

3. Clinical Advisory Panel • Deborah Ayers RN, MSN - State QI Nurse • Chris Glue- Restorative CNA - Dimondale, Lansing • Teresa Gurny, RN/DON - Medilodge of Howell • Dr. Steve Levenson- Geriatrician - Baltimore, Maryland

4. Clinical Advisory Panel (cont.) • Sue Mangan - Pharmacist/Surveyor -Metro West Team • Julie Savage, RN, MSN – Eden CMCF • Nancy Wong, RN, BSN - ADON/In-service Director/Woodward Hills NC • Barbara Zabitz RD/Surveyor - Metro West Team

5. Guideline Format • Basic Care Process Steps • Expectations of facilities related to steps • Rationale for expectations • Documentation Check list • Relevant Tables

6. Heart Failure • A constellation of signs/symptoms that result from the inability of the heart to pump blood to the body at a rate the body needs.

7. Care Process Steps It always begins with an “Assessment”

8. Residents with history/or risk factors for heart failure Transfer data Labs, EKG, echo, chest film Anemia, COPD, other lung diseases Previous treatment Hospitalization for heart failure. Assessment

9. Coronary artery disease Angina/infarction Chronic hypertension Idiopathic dilated cardiomyopathy Valvular heart disease Arrhythmia Anemia Fluid volume overload with noncardiac causes Thyroid disease Assess Risk Factors

10. New admissions with CHF • Look for signs and symptoms • Diagnostic test results • Document the findings

11. Staff and practitioner . . . identify The severity and consequences of heart failure

12. Systolic Dysfunction Left ventricle has reduced muscle contractility Diastolic Decreased left ventricular filling Caused by ventricular stiffness, decreased rate of relaxation, or rapid heart rate Myocardial Dysfunction

13. Class I No limitations of physical activity. No shortness of breath, fatigue, or heart palpitations with ordinary physical activity. Class II Slight limitation of physical activity. SOB, fatigue, heart palpitations. Patient comfortable at rest. Class III Symptoms with minimal exertion. SOB, fatigue, heart palpitations. Patients comfortable at rest. Class IV Severe to complete limitation of activity. SOB, fatigue, heart palpitations, even at rest. Functional Assessment

14. American College of CardiologyAmerican Heart Association • Stage A High risk of HF, no structural heart abnormality • Stage BStructural heart disorder, no symptoms • Stage CStructural disorder, past or current HF symptoms • Stage DEnd-stage disease, requiring specialized treatment

15. Diagnosis/Cause Identification • Practitioner and staff clarify known causes of a resident’s heart failure, or seek causes if not identified.

16. with terminal/end stage conditions if it would not change management in a resident that refuses treatment if burden of the work-up is greater than the benefit of the treatment if causes are reversible Is a work-up appropriate?

17. What’s in a work-up? • History/exam • Lab tests • Chest x-ray • EKG • All look for reversible causes of CHF

18. Treatment/Problem Management • Heart failure treatment: • Based on established recommendations (i.e. best practice/http://www.acc.org) • Consistent with resident choices, values overall condition, and prognosis.

19. Establish goals • Prolong life • Prevent worsening • Improve quality of life • Provide comfort care

20. Treatment/Problem Management Did the staff and practitioner treat contributing factors and underlying causes of heart failure?

21. Arrhythmia Pulmonary embolism Accelerated/malignant hypertension Thyroid disease Valvular heart disease Unstable angina Fluid volume status Renal failure Medication-induced High salt-intake Severe anemia Like what??

22. Treatment • Base therapy on the presence/absence of fluid volume overload, nature of dysfunction • Include annual flu and pneumococcal vaccination • Resident’s goals, choices, values, are always considered

23. Consider other relevant interventions • Dietary counseling • Diet modification • Exercise • Smoking cessation • Address end-stage HF

24. Monitoring Implement approaches to manage the individual with heart failure

25. Monitoring • Collaboration between the facility, medical director, and practitioner

26. Evaluation and Documentation • Document assessment of heart function - any complications? • Evaluate and document reasons why a resident failed to achieve cardiac/functional goals • Review medication regime and modify as needed

27. Monitoring • Complications in an effort to “treat” heart failure can occur.

28. Bibliography • AMDA Clinical Practice Guideline – Heart Failure, 2002 • Aquilani, R, et. al. Is nutritional intake adequate in chronic heart failure patients? Journal of the American College of Cardiology. 2002 (Vol. 2) (7) • Carboral, M.F. Putting the 2005 American College of Cardiology/American heart failure association heart failure guideline into clinical practice: advice for advance practice nurses. Retrieved June 30, 2006 from http:// www. Medscape .com/view article/533626

29. Bibliography • Ferris, Mara. Geriatric Emergency Assessment & Prevention. 2002; PESI, Eau Clare, WI. • Steefel, Lorraine, RN, MSN. New Advances Offer Hope for Treating Heart Failure. Nursing Spectrum, March 2004; pp12-13.