Early Recognition and Management of Heart Failure

1. Early Recognition and Management of Heart Failure Meeting 1 Presenter’s Name Presenter’s Title Presenter’s Email

2. Early Recognition and Management of Heart Failure Program Design • Evidence-based and best practice education and training on protocols and tools necessary for early recognition of and management of Heart Failure (HF) • Interactive and integrated team approach with all health professionals, including certified nurse assistants in skilled nursing facilities (SNF)s • Case-based approach • Utilizes Performance Improvement Plan • Includes SNFs and hospital • Required data collection over the period of the improvement project and includes how to track and trend those data

3. Expectations Hospital/QIO Expectations: Facility Expectations: • Implement a HF Tracking tool and treatment protocols as provided in Early Recognition and Management of Heart Failure Program • Participate in scheduled learning sessions (total of 3 or 4) • Participate in a minimum of two coaching calls • Baseline and Monthly Submission of outcome and process data • Use this toolkit to collaborate with SNF for ongoing staff education and quality improvement • Defined process and outcome measures to measure success

4. Early Recognition and Management of Heart Failure Program • Collaboration between Hospital and SNF • Establish standards • Assess current state • Educate staff • Implement program • Evaluate program

5. Assessing Current State Readiness Evaluation Pre-Training Assessment Complete assessment Use this tool with your staff to assess their knowledge pre and post education

6. Utilize Heart Failure Toolkit

7. Heart Failure Statistics • Around 5.8 million people in the United States have HF • HF ranks as the most frequent cause of hospitalization and re-hospitalization among older Americans with 1.1 million discharges with HF as primary diagnosis • Accounts for over 3 million urgent outpatient visits • Mortality: 20-30 % die within 1 year, 50-60% in 5 years, worse than most common cancers • In 2010, heart failure will cost the United States $39.2 billion. This total includes the cost of health care services, medications, and lost productivity.

8. Post Acute Care following a Cardiac Event • Post Acute Care services include • Skilled Nursing Facilities • Home Care Agencies • Medical Care by Primary Care Physicians and Specialists • Percentage of cardiac event patients who used post acute care from a 2003 Medicare part A database • Cardiac valve surgery 55% • Acute MI 50% • Heart Failure 45% • CABG 44% • PCI 10% Dolansky, Mary, et al. 2010. Post-Acute Care Services Received by Older Adults Following a Cardiac Event. A Population-Based Analysis. Journal of Cardiovascular Nursing. 25:4. 342-349

9. Discharge to a Skilled Nursing Facility and Subsequent Clinical Outcomes Among Older Patients Hospitalized for Heart Failure • Using Get with the Guidelines Heart Failure Registry, evaluated 15459 Medicare beneficiaries • 24% discharged to SNF • 22% discharged home with home health service • 54% discharged home with self-care • Wide variety of patient factors are associate with discharge to a SNF versus home. Patients discharged to a SNF included: • longer length of stay • advanced age • variety of comorbidities • Patients discharged to SNF with high rates of adverse events • Discharged home: 30 day mortality of 4.1% and 1-year mortality rate of 29.1% • Discharged to SNF: 30 day mortality rate of 14.4% and 1-year mortality rate of 53.5% • Discharge to SNF characterized by criteria such as poor mobility, cognitive impairment, frailty and poor-in-home support Allen, Larry et al. 2011. Discharge to a Skilled Nursing Facility and Subsequent Clinical Outcomes Among Older Patients Hospitalized for Heart Failure . Circulation Heart Failure.4: 293-300

10. Collaboration between hospital and SNF’s

11. Hospital SNF Heart Failure Post Discharge Care Protocol Heart Failure Hospital Discharge Checklist • Physician discharge summary available in discharge packet • Visual Notification placed on discharge packet • Cardiology follow-up appointment documented • Discharge weight and estimated dry weight (or dialysis dependent) documented • Dietary restrictions and follow-up labs documented in discharge summary • Baseline edema, respiratory status, oxygen requirement documented

12. Hospital SNF Heart Failure Post Discharge Care Protocol Facility RN/LPN Checklist • On Admission: • Assess edema, respiratory status, oxygen requirement and verify with information from Hospital • Verify diuretic dosage, follow up labs • Initiate Heart Failure Trends log (paper or electronic) • Ongoing Assessment: • Check and record BP/P/RR/temp/pulse ox/pain Q shift for first 7 days following admission, then follow facility protocol • Assess edema, respiratory status, oxygen requirement Q shift for first 7 days, then follow facility protocol Chart daily (AM) on Heart Failure Trends log (paper or electronic) • Provide and reinforce Heart Failure teaching with patient and family using teach back methodology • On Discharge: • Identify PCP and make follow-up appointment with PCP or cardiologist • Ensure medication reconciliation is performed and/or reviewed by Attending Physician on discharge • Give copy of Heart Failure Trends log to patient to take with them to their PCP appointment

13. Hospital SNF Heart Failure Post Discharge Care Protocol Facility CNA Checklist • Weigh patient on arrival, chart in Heart Failure Trends log (paper or electronic) • Weigh patient every morning, before breakfast, at the same time each day, on the same scale, after voiding and wearing similar clothes • Chart results in Heart Failure Trends log (paper or electronic)

14. Hospital SNF Heart Failure Post Discharge Care Protocol Facility Clerk Checklist • Visual notification placed on patient’s chart • Discharge labs, physician’s discharge summary from Hospital placed on patient’s chart • Identify date of cardiology follow-up appointment and communicate to nurse, patient and family • Arrange transport for follow-up cardiology appointment • Ensure Attending Physician H&P, Heart Failure Trends log, current medications and recent labs accompany patient for cardiology appointment

15. SNF Heart Failure Post Discharge Care Protocol Facility dietary/nutrition checklist • Help patient identify low salt/ sodium foods on menu • Provide patient and family education on sodium and fluid restriction and surveillance using teach back methodology

16. Hospital - SNF Heart Failure Post Discharge Care Protocol

17. SNF Heart Failure Post Discharge Care Protocol Heart Failure Trends Dry weight (per Hospital):_________________________ Weight on admission:______________________________ Creatinine on admission:__________________________

18. Follow-up to Establishment of Protocols Education provided to SNF providers Process Measurement • Educational sessions provided to Nursing and Assistive staff within the SNF • Further discussion with SNF leadership staff will occur to collaboratively identify best practices within SNF in care of Heart Failure patients • Generic process measures collected for all patients, not specifically for heart failure patients, submitted to MPRO • Specific HF measures being captured for list of HF patients discharged to the SNF • List generated by hospital quality department and sent to SNF

19. Process Measurement A method of identification of HF patients instituted in the SNF, which includes the following for patient care: Upon Admission to SNF: • The SNF audits compliance with provider evaluation of new HF admissions within 24 hours of admission. Audit results should be shared with the hospital quarterly. • The SNF ensures that all HF patients that were scheduled for an appointment at cardiology on hospital discharge keep/attend the appointment. Necessary transportation accommodations are made. During SNF Stay: • Charting of daily weight and daily weight logs are being audited on a routine basis. Audit results should be shared with the hospital quarterly or as determined by the hospital and SNF. • Ensure patient compliance with dietary restriction prescribed on hospital discharge while the patient is in the SNF.

20. Process Measurement Continued A method of identification of HF patients instituted in the SNF, which includes the following for staff education: Prior to Discharge From SNF: • All HF patients discharged from the SNF to the community are set up with a PCP follow-up appointment within 3-5 days. • Arrange a follow-up appointment with a cardiologist prior to discharge from the SNF. • All front line staff are receiving HF education. • HF education has been incorporated into new employee orientation at the SNF.

21. Discharge From SNF to Community • Team of SNF physicians with heart failure expertise • Integrated with the Hospital Medicine division • Emphasis on quality of care • Expectation to see new patients in SNF within 24 hours of admission • Access to inpatient information, providers and EMRs • Discharge summary including med list sent to PCPs within 2 days of SNF discharge

22. Education for SNF Staff Members 3

23. Behavioral Objective for Staff Education Upon completion of presentation, participant will: • Discuss the pathophysiology of heart failure and treatment • Describe the outward signs and symptoms of heart failure • Describe the appropriate medications, diagnostics and bedside care for a heart failure patient • Recognize the entire continuum of interventions which may be available for a patient with heart failure • Describe the challenges in the transition of a patient with acute heart failure from acute care hospital (ACH) to a skilled nursing facility

24. Case Example Mr. WS is a 78 year old male who was admitted with shortness of breath and swelling in his abdomen. In the ED, he was admitted with a diagnosis of acute on chronic systolic and diastolic heart failure. Due to dyspnea on exertion, Mr. WS was unable to progressively ambulate and became debilitated. During Interdisciplinary Rounds, the team reviewed the Physical Therapy evaluation notes which included the recommendation for discharge to Subacute Rehab. The Case Manager shared the information with Mr. and Mrs. WS and a facility was chosen. Prior to transfer to a Skilled Nursing Facility for rehabilitation, WS experienced care within the hospital.

25. Admission Data for WS Past Medical History Physical Assessment and Labs • Coronary Artery Disease with previous Coronary Artery Bypass Surgery • HTN, Hyperlipidemia • Diabetes mellitus • COPD • Cardiomyopathy with diastolic and systolic heart dysfunction, EF 20% • Biventricular Pacer with ICD • Chronic kidney disease, stage III • BP 94/55 • HR 59, atrial fibrillation, • Resp rate 23, pulse ox 95% on 2 L Nasal Cannula • 2+ pitting edema bilateral lower extremities, • Large abdomen • HGB 10.0, Hct 30.1 • K 3.1 • BUN 50, Creat 2.95, GFR 21 • BNP 1303

26. What is Heart Failure? • A syndrome resulting from any structural or functional cardiac defect limiting the ability of the ventricle to fill with or eject blood • HF is diagnosed on the presence of characteristic signs and symptoms and not only on the basis of any diagnostic tests • The most common causes of heart failure are coronary artery disease, high blood pressure, and diabetes

27. Characteristics of Heart Failure Heart failure is progressive and characterized by: • left ventricular dysfunction • neurohormonal dysregulation • fluid retention • reduced exercise tolerance • shortness of breath • shortened life expectancy

28. Cardiac Irritant Symptoms appear and increase EF falls <40% Asymptomatic Left Ventricular Dysfunction Clinical Heart Failure = = CAD Longstanding HTN The Heart Failure Continuum

29. Systolic Heart Failure Occurs as a Result of Adverse Ventricular Remodeling

30. Ventricular Remodeling - Illustration Ventricular remodeling. Cross-sectional view of left and right ventricles: a, normal; b, concentric hypertrophy; and c, eccentric hypertrophy. Abbreviations: LV, left ventricle; RV, right ventricle. Produced and printed with permission from The Cleveland Clinic Foundation; Cleveland, Ohio.

31. Vicious Cycle of Heart Failure LV Dysfunction Decreased cardiac output and Decreased blood pressure Increased cardiac workload (increased preload and afterload) Frank-Starling Mechanism Ventricular Remodeling Neurohormonal activation Increased cardiac output (via increased contractility and heart rate) Increased blood pressure (via vasoconstriction and increased blood volume)

32. Heart Failure Prognosis • 20-30% mortality in 1 year, 50-60% in 5 years (worse than most common cancers) • In patients with persistent NYHA Class IV symptoms, 1 yr mortality is 30-50% • Mortality risk factors: older age, lower LVEF, worse symptoms, higher BNP, hyponatremia, lower systolic BP, higher BUN, PAD, anemia, dementia, frailty

33. Types of Heart Failure There are several ways to clinically classify heart failure: Coding classifications and definitions focus primarily on systolic versus diastolic (or both) and acute versus chronic (or both).

34. Types of Heart Failure: New York Heart Association Classes

35. Stages of Heart Failure: American College of Cardiology At Risk for Heart Failure: STAGE A: High risk for developing HF STAGE B: Asymptomatic LV dysfunction Heart Failure: STAGE C: Past or current symptoms of HF STAGE D: End-stage HF • Designed to emphasize preventability of HF • Designed to recognize the progressive nature of LV dysfunction

36. Symptoms and Signs of Right Sided vs Left Sided Heart Failure Right Sided Failure • Symptoms • Abdominal pain • Anorexia • Nausea • Bloating • Swelling • Physical signs • Peripheral edema • Jugular venous distention • Hepatic engorgement • Contributing factors • Left sided failure • Pulmonary disease, COPD Left Sided Failure • Symptoms • Dyspnea on exertion • Paroxysmal nocturnal dyspnea • Tachycardia • Cough • Physical signs • Basilar rales • Pulmonary edema • S3 gallop • Pleural effusions • Contributing factors • CAD • Hypertension

37. Systolic (HFrEF) vs Diastolic (HFpEF)Heart Failure

38. Physical Assessment

39. What are the signs and symptoms of HF?

40. Assessment for Acute Decompensated Heart Failure Watch for signs of poor perfusion • Altered mental status • Decreased urine output • Cool, clammy skin • Sluggish capillary refill • Low blood pressure

41. Checking for Edema +3 6 mm +4 8 mm +1 2 mm +2 4 mm

42. What else can we use to assess? Diagnostics

43. Treatment of Heart Failure

44. The Hospitalized Patient—What we worked to achieve • Stabilize systemic perfusion if necessary • If fluid overloaded, IV loop diuretics • Initially equal or greater than oral outpatient dose • Later guide by urine output and signs / symptoms • Increase dose? • Continuous IV diuretic infusion • Add 2nd medication (metolazone, spironolactone) • While on IV diuretics or changing HF meds, daily basic metabolic panels • Monitor I/Os, vital signs, body weight daily • Check signs and symptoms of perfusion and congestion both supine and standing

45. Use of Diuretics Types of Diuretics Adverse Effects • Precipitation of metabolic abnormalities • May predispose to arrhythmias • Worsening of renal function • May precipitate cardiorenal syndrome if used inappropriately • Lower the dose as tolerated once euvolemic state is achieved

46. Dry Weight Calculation and plan to attain dry weight for discharge • Recommend exploring the algorithm described in this article: • Thomas M. O’Brien, Santosh Menon, Tracy Stephens, et al. (2012). Algorithm‐Based Assessment of Target Weight Removal in Acute Decompensated Heart Failure. Congestive Heart Failure, 18(1), 43-46.

47. Daily Weights • Daily weights are the most effective method of tracking fluid status, more effective than measurement of Intake and Output • Physician calculates the Estimated Dry Weight (EDW) based on algorithm and this becomes the goal or target weight to achieve and maintain • Weigh patient daily while hospitalized or under health provider care • Same time every day preferably first thing in AM • Minimal clothing • Prior to breakfast and post void • Record daily weight in a stable place in the record • Notify clinician if weight up 2 pounds overnight or 4-5 pounds in 1 week • Treatment may include diuretic dose (water pill) adjustment or careful watching

48. Heart Failure: Medication Overview Rx to avoid: NSAIDs, Most anti-arrhythmics, Most Ca2+ channel blockers

49. Nursing Treatment and Monitoring

50. Identification of Heart Failure Exacerbation • HF is dynamic with rapid changes in condition • Monitor vital signs closely physician order • Heart Rate, Blood Pressure, Respiratory Rate, Pulse Oximetry • Daily weights must be accurate Harrington, C (2012). Assessing heart failure in long-term care facilities. In D.P Schoenfelder. Series on evidence-based practice guidelines: Iowa City: the University of Iowa College of Nursing John A Hartford Foundation Center of Geriatric Nursing Excellence