Home Care Infusion Management of Heart Failure

1. Home Care Infusion Management of Heart Failure Margaret Lyons DNP, RN, CRNI Villanova University / Jefferson Home Infusion Service Villanova and Philadelphia, Pa. margaret.g.lyons@villanova.edu

2. Incidence & Prevalence HF or congestive heart failure (CHF) is a disease state that afflicts approximately 6.6 million U.S. (Roger et. al, 2012) HF is the preferred term to use as not all patients with this disorder experience fluid accumulation or congestion. (Rosa, 2008) Each year, 670,000 patients are newly diagnosed with the disease. (CDC, n.d.) More common in African American and Hispanic males. (Roger et.al, 2012) Dominates in the elderly – 11% over 80 years. (Iyngkaran, et. al 2015)

3. Risk Factors Major Clinical Risk Factors • Age, male gender • Hypertension, LVH • Myocardial infarction • Diabetes mellitus • Valvular heart disease • Obesity Toxic Risk Precipitants • Some Chemotherapies • Cocaine • NSAIDs • Alcohol Genetic Risk Predictors • SNP (e.g., 2CDel322-325, 1Arg389) Morphologic Risk Predictors • Increased LVID, mass • Asymptomatic LV dysfunction • LV diastolic dysfunction Minor Clinical Risk Factors • Smoking • Dyslipidemia • Sleep-disordered breathing • Chronic kidney disease • Albuminuria • Homocysteine • Immune activation, IGF1, TNF, IL-6, CRP • Natriuretic peptides • Anemia • Dietary risk factors • Increased HR • Sedentary lifestyle • Low socioeconomic status • Psychological stress Schocken D. D., Benjamin, E., Fonarow, G. C., Krumholz, H. M., Levy, D., Mensah, G. A. (2008). Functional Genomics and Translational Biology Interdisciplinary Working Group.

4. Diagnosis / Functional Classification Diagnosis: • + H+P with symptomatology • ↑Type B natriuretic peptide (BNP) or • ↑N-terminal pro b-type natriuretic peptide (NTproBNP) levels • Elevated cardiac troponin • LVEF levels ≤35% (HFSA, 2010; NICE, 2010; Jessup et al., 2009) Classifications: New York Heart Association’s (NYHA) method is generally used to classify function. American College of Cardiology (ACC) / American Heart Association’s (AHA)system is used for staging. Patients in NYHA Class IV (severe) and ACC/AHA stage D (refractory) could be candidates for inotropic therapy (HFSA, 2010).

5. New York Heart Association (NYHA) Classification • Class I (mild): Diagnosis of HF is made but patient experiences minimal symptoms. Focus of treatment is on regular exercise, limiting alcohol consumption, and eating healthy with moderate sodium intake. Hypertension if present is treated and smoking cessation is crucial. • Class II (mild): Patients exhibit symptoms with physical activity like bending over or walking. Medications like ACE-inhibitors or beta-blockers may be considered. • Class III (moderate): Patients experience limitations (fatigue and shortness of breath) during physical activity but are usually comfortable at rest. HCP should monitor diet and exercise and diuretics may be prescribed. • Class IV (severe): Patients cannot exert themselves and show significant signs of cardiac problems even while resting. Surgical options will be explored.

6. American College of Cardiology (ACC) /American Heart Association (AHA) Staging Stage A (High Risk): No symptomatology but have several of the risk factors for HF development (obesity, highfat or sodium diet, smoking, alcohol intake, drug use or abuse, and lack of physical exercise, diabetes, infection, advanced age, or family history. Stage B (Asymptomatic): Diagnosis of HF but not experiencing symptoms. Healthcare providers will be monitoring or treating underlying causal process like HTN and may be prescribed an ACE inhibitor or beta-blocker. Stage C (Symptomatic):Cardiac dysfunction is present with symptomatology like fatigue and shortness of breath. Attention should be paid to supervised exercise, healthy diet with low sodium intake, and little to no alcohol consumption. Stage D (Refractory/End Stage): Signs and symptoms of HF persists after treatment and therapy. Monitoring of diet, exercise, and blood pressure are still adhered to and patients will probably be prescribed medications and can include surgical options (depending on severity) such as a conventional pacemaker, a ventricular device such as a BiV pacemaker, LVR surgery, or heart transplantation.

7. Prognosis The associated morbidity and mortality is high. One of five people will not be alive one year from the date of diagnosis (CDC, n.d.). Half of all patients diagnosed with HF will die within five years (Roger et al., 2012). End stage HF has limited treatment options.

8. Patient Assessment Symptoms *Shortness of breath (SOB) Orthopnea Paroxysmal nocturnal dyspnea (PND) *Generalized fatigue Weakness and exercise intolerance *Study by Kato et al. (2012) worst symptoms reported by patients. Additional Symptoms: *Fluid retention, with possible weight gain and swelling of the feet, ankles, or abdomen. Jugular venous distention (JVD) and hepatomegaly. S3 (ventricular gallop) (cardinal sign in older adults) S4 (atrial gallop) HX myocardial infarction (MI), chronic HTN or Aortic stenosis (AS)

9. Jack - Heart Failure Client History – Obesity, HTN, MI, Depression, CVA post cardiac catheterization (no neurological deficits),, Asthma / COPD, Chronic Renal Insufficiency and Prostate Cancer

10. Effective Management is Key HF’s course is characterized by frequent exacerbations and periods of control. Center for Medicare & Medicaid Services (CMS) mandates will not cover hospital and home care costs for a patient readmitted within 30 days of a discharge where HF was the admitting diagnosis. (Stone & Hoffman, 2010) Penalties for readmissions have been authorized by the Hospital Readmission Reduction Program began in 2013. (Stone & Hoffman, 2010) Private health care insurers are considering reimbursement penalties similar to those of CMS, making managing HF in a manner that decreases recidivism highly relevant. (Sommers & Cunningham, 2011) HF management in the home is less costly than routine hospital care. (Frick, Burton, Clark et al. 2009)

11. Home Infusion Therapy: Twofold Bridge “Bridge to transplant” in adults and children and as a way to manage advanced HF until end of life.

12. Types of Home Therapies Lifestyle Modification Oral medications Implanted Devices • Pacemakers • Defibrillators • Chronic Resynchronization Therapy (CRT) • Left ventricular assistive devices (LVADs) IV Medications and Infusion • Furosemide • Inotropes – Dopamine, *Dobutamine and *Milrinone (*more common in home)

13. Furosemide Indications • Edema due to heart failure, hepatic impairment or renal disease. • Hypertension. Action • Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. • Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium. • Effectiveness persists in impaired renal function. Half – life - 30–60 min (↑ in renal impairment) Dosage • IM: IV: (Adults) 20–40 mg, may repeat in 1–2 hr and ↑ by 20 mg every 1–2 hr until response is obtained, maintenance dose may be given q 6–12 hr; Continuous infusion– Bolus 0.1 mg/kg followed by 0.1 mg/kg/hr, double q 2 hr to a maximum of 0.4 mg/kg/hr. • IM: IV: Children 1–2 mg/kg/dose q 6–12 hr Continuous infusion– 0.05 mg/kg/hr, titrate to clinical effect. http://www.drugguide.com/ddo/view/Davis-Drug-Guide/51345/all/furosemide

14. Most Common Home Inotropes (Lyons & Carey, 2013)

15. Treatment Guidelines National Institute for Health and Clinical Excellence(NICE) Heart Failure Society of America (HFSA) American College of Cardiology Foundation (ACC) and the American Heart Association (AHA) The ACCF/AHA guidelines (2009) state that “the decision to continue intravenous infusions at home should not be made until all alternative attempts to achieve stability have failed repeatedly, because such an approach can present a major burden to the family and health services and may ultimately increase the risk of death” (p. 1362). Therefore, clinical judgment and collaboration with the patient regarding all possible treatment options is paramount to deliver Guideline Directed Medical Therapy (GDMT). Intermittent infusion not supported by ACC / AHA. Use of continuous Inotropes is not preferred if patient is candidate for Mechanical Circulatory Support or Transplantation as morbidity with use is high (2013).

16. Management of Home Infusion Therapies for HF (ADOPIE) • Assessment • Nursing Diagnosis of pertinent issue(s) • Outcome Planning(care based on self-care approach) • Implementing interventions • Evaluation (client condition / need for additional referrals for further interventions)

17. Role of the Infusion Nurse • Discharge Planning • Working with reimbursement personnel • Collaborating to choose an appropriate access device for client • Care and maintenance of access device • Patient Education (crucial) includes: explanation of disease, symptoms to report and behaviors to help modify exacerbations, IV medication administration of medication to client / caregiver.

18. Discharge Planning Gorski’s 7 Key Questions to Address 1) Is the patient willing and able to participate in the home infusion therapy (HIT)? 2) Is the patient clinically stable, and has the HIT plan been identified? 3) Is a caregiver required at home during infusions? 4) Is the infusion access device appropriate for home care? 5) Can the patient’s therapy be interrupted during the transportation from hospital to home? 6) Are there any home environmental issues? 7) Is there appropriate reimbursement for home care? (Gorski, 2005)

19. Access Device • Need true central line (meds are vesicant) Unless client only needs intermittent furosemide could have a peripheral IV. • PICC or Implanted Port with tip ending in Right Atria or lower third of SVC • If PICC – 2 lumens in case of occlusion.

20. Reimbursement Issues • Milrinone more $$$ than Dobutamine but not as expensive as readmission. • Some insurance companies want extensive testing prior to authorization which may or may not have been completed during stay i. e. hemodynamic cardiac monitoring to show that inotrope improved Cardiac Index (CI) and Pulmonary Capillary Wedge Pressures (PCWP). • Sometimes documented symptom improvement will suffice.

22. Client Education / Nurse Education Lifestyle Management • Diet (Na and fluid restrictions) • Weight loss • Smoking cessation • Oral medication use (diuretics) Symptoms to Report (can use tele-monitoring or apps -if available and patient is interested in using) • Daily weights, BP (hypotension), edema, SOB and orthopnea IV Administration • Back up pump and spare med • No flushing to avoid bolus • Storage of meds and supplies • Visit frequency to expect RN • Inotrope dependency Nurse Competencies • CVC / PICC dressings • Phlebotomy • Peripheral IV insertion • Dose per minute calc / volume per hour calculation • JVP estimations (www://wn.com/jugular_venous_distension_example) • Inotrope and beta blockers (MOA) • Creatinine monitoring • Vesicant nature of drug • Central line infection monitoring • Motivational Interviewing (MI)

24. E-Health Technologies 7 in 10 (69%) US adults track a health indicator for themselves or a loved one. (Iyngkaran, et al., 2015) Patient Examples Clinician Examples Activity monitoring Electronic Health Records (EHR) (Fitbit, Jawbone, NikeFuel) (ehealth.gov, WellnessFX, Epic) Diet apps (myfitness Pal, Fatsecrets) Clinical Decision Support Systems Sleep tracking Self reported data from pt apps & EHR (sleep bug) Apple HealthKit, Physiological monitoring devices Google Fit platforms • HR Microsoft Healthvault • (Polar, Mio, Pulseon) • Wireless Scales Online Ways to provide Feedback to Patients • (Aria, iHealth) Email, Health portals • BP Video conferencing , SKYPE • (iHealth) • Data from Internal Devices • From manufacturer Peer support (patientslikeme, healthshare)

25. Teaching Medication Administration • Caregiver required. • Pump use – alarms and setting up infusion, need for spare pump and medication bag in case of malfunction. • When to call RN – occlusion, redness or swelling of PICC / CVP, trouble with infusion, change in status – weight, SOB etc.

26. Outcomes / Risks • Improved symptomatology • Increased functional status • Increased hemodynamic function • Decreased hospital admissions • Decreased length of stay when hospitalized • Allows for patients to remain home with loved ones (especially critical to pediatric patients awaiting transplant) • Cost effective • Potential line infection • Potential development of arrhythmias • Many clients have implanted defibrillators • Potential hypotension • Potential for sudden death • High mortality rates

27. Barriers to Successful Treatment • Geography, staffing, health literacy, depression, cognitive impairment, low self-confidence, age, culture, co-morbidities, lower socioeconomic status and lifestyle factors.

28. Future Heart Failure Therapies • New pharmaceutical options • Natriuretic peptides, calcium sensitizers, sarcolemmal calcium receptor or Na–K ATPase agents, free fatty acid metabolism modulators, and cardiac myosin activators • Improved availability of donor organs • More sophisticated mechanical devices such as heart pumps • Stem cell therapy • Gene therapies • CUPID trial

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31. References Jaski, B. E., Jessup, M, I., Mancini D. M., Cappola, T. P., Pauly, D. F., Greenberg, B., … & Hajjar, R. J. (2009).Calcium Upregulation by Percutaneous Administration of Gene Therapy in Cardiac Disease (CUPID Trial), a First-in-Human Phase 1/2 Clinical Trial. Journal of Cardiac Failure, 15(3), 171-181.doi:  10.1016/j.cardfail.2009.01.013 Yancy, C. W., Jessup, M., Bozkurt, B., Burler, J., Casey, D. E., Drazner, …..& Wilkoff, B. L. (2013). ACCF /AHA Guidelines for the Management of Heart Failure in Adults – A Report of the American College of Cardiology Foundation / American Heart Association Task Force on Practice Guidelines. Circulation, 128, e240-e327. doi: 10.1161/CIR.0b013e31829e8776 Kato, M., Stevenson, L. W., Palardy, M., Campbell, P. M., May, C. W., Lakdawala, N.K., …& Setoguchi, S. (2012). The Worst Symptom as Defined By Patients during Heart Failure Hospitalization: Implications for Response to Therapy, Journal of Cardiac Failure, 18(7), 524-533. National Institute for Health and Clinical Excellence (NICE). (2010). Chronic heart failure – management of chronic heart failure in adults in primary and secondary care. Retrieved from http://guidance.nice.org.uk/CG108/NICEGuidance/pdf/English Roger, V.L., Go, A.S., Lloyd-Jones, D.M., Benjamin, E.J., Berry, J.D., Borden, W.B., … & Turner, M. B on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. (2012). Heart Disease and Stroke Statistics—2012 Update: A Report from the American Heart Association. Circulation, 125, e2-e220. doi: 10.1161/​CIR.0b013e31823ac046  Rosa, M. A. (2008). How a Heart Failure Home Care Disease Management Program Makes a Difference. Home Healthcare Nurse, 26(8), 483-490.  Schocken , D. D., Benjamin, E., Fonarow, G. C., Krumholz, H. M., Levy, D., Mensah, G. A., …& Hong, Y. (2008). Prevention of heart failure: A scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation, 117, 2544-2565.  Sommers, A. & Cunningham, P. J. (2011). Physician Visits after Hospital Discharge: Implications for Reducing Readmissions. National Institute for Health Care Reform, Research Brief, No. 6, Retrieved from http://www.nihcr.org/Reducing_Readmissions.html Stone, J. & Hoffman, G. J. (2010, September, 21). Medicare Hospital Readmissions: Issues, Policy Options and the PPACA. Congressional Research Service (CRS) Report R40972. Retrieved from www.crs.gov. 1-37.