Heart Failure Clinical Process Guideline

Deborah Ayers, RN, MSNDeborah Ayers, RN, MSN

Quality Improvement Nurse Quality Improvement Nurse ConsultantConsultant

General Information

““Optional” Best Practice ToolOptional” Best Practice Tool Effective date for usage Effective date for usage

Electronic copies of the tool are Electronic copies of the tool are

available on the websiteavailable on the website http://michigan.gov/bhshttp://michigan.gov/bhs; click “Best ; click “Best

Practice Information & GuidelinesPractice Information & Guidelines””

Clinical Advisory Panel

Deborah Ayers RN, MSN - State Deborah Ayers RN, MSN - State QI NurseQI Nurse

Chris Glue- Restorative CNA - Chris Glue- Restorative CNA - Dimondale, LansingDimondale, Lansing

Teresa Gurny, RN/DON - Teresa Gurny, RN/DON - Medilodge of HowellMedilodge of Howell

Dr. Steve Levenson- Geriatrician Dr. Steve Levenson- Geriatrician - Baltimore, Maryland- Baltimore, Maryland

Clinical Advisory Panel (cont.)

Sue Mangan - Pharmacist/Surveyor Sue Mangan - Pharmacist/Surveyor -Metro West Team-Metro West Team

Julie Savage, RN, MSN – Eden CMCFJulie Savage, RN, MSN – Eden CMCF Nancy Wong, RN, BSN - ADON/In-Nancy Wong, RN, BSN - ADON/In-

service Director/Woodward Hills NCservice Director/Woodward Hills NC Barbara Zabitz RD/Surveyor - Metro Barbara Zabitz RD/Surveyor - Metro

West TeamWest Team

Guideline Format

Basic Care Process Basic Care Process StepsSteps

Expectations of Expectations of facilities related to facilities related to stepssteps

Rationale for Rationale for expectationsexpectations

Documentation Documentation Check listCheck list

Relevant TablesRelevant Tables

Heart Failure

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

Care Process Steps

It always begins with an It always begins with an “Assessment”“Assessment”

Assessment

Residents with Residents with history/or risk history/or risk factors for factors for heart failureheart failure

Transfer dataTransfer data Labs, EKG, echo, Labs, EKG, echo,

chest filmchest film Anemia, COPD, Anemia, COPD,

other lung other lung diseasesdiseases

Previous Previous treatmenttreatment

Hospitalization Hospitalization for heart failurefor heart failure..

Assess Risk Factors

Coronary artery Coronary artery diseasedisease

Angina/infarctionAngina/infarction Chronic Chronic

hypertensionhypertension Idiopathic Idiopathic

dilated dilated cardiomyopathycardiomyopathy

Valvular heart Valvular heart diseasedisease

ArrhythmiaArrhythmia AnemiaAnemia Fluid volume Fluid volume

overload with overload with noncardiac noncardiac causescauses

Thyroid diseaseThyroid disease

New admissions with CHF

Look for signs and symptomsLook for signs and symptoms

Diagnostic test resultsDiagnostic test results

Document the findingsDocument the findings

Staff and practitioner . . . identify

The severity The severity and and consequences consequences of heart failureof heart failure

Myocardial Dysfunction

Systolic DysfunctionSystolic Dysfunction

Left ventricle has Left ventricle has reduced muscle reduced muscle contractilitycontractility

DiastolicDiastolic

Decreased left Decreased left ventricular fillingventricular filling

Caused by Caused by ventricular ventricular stiffness, stiffness, decreased rate of decreased rate of relaxation, or relaxation, or rapid heart raterapid heart rate

Functional Assessment Class IClass I

No limitations of No limitations of physical activity. No physical activity. No shortness of breath, shortness of breath, fatigue, or heart fatigue, or heart palpitations with palpitations with ordinary physical ordinary physical activity.activity.

Class IIClass II Slight limitation of Slight limitation of

physical activity. SOB, physical activity. SOB, fatigue, heart fatigue, heart palpitations. Patient palpitations. Patient comfortable at rest.comfortable at rest.

Class IIIClass III Symptoms with Symptoms with

minimal exertion. minimal exertion. SOB, fatigue, heart SOB, fatigue, heart palpitations. Patients palpitations. Patients comfortable at rest.comfortable at rest.

Class IVClass IV Severe to complete Severe to complete

limitation of activity. limitation of activity. SOB, fatigue, heart SOB, fatigue, heart palpitations, even at palpitations, even at rest.rest.

American College of Cardiology

American Heart Association Stage AStage A High risk of HF, no High risk of HF, no

structural structural heart abnormalityheart abnormality Stage BStage B Structural heart disorder, no Structural heart disorder, no

symptoms symptoms Stage CStage C Structural disorder, past or Structural disorder, past or

current HF symptomscurrent HF symptoms Stage DStage D End-stage disease, requiring End-stage disease, requiring

specialized treatment specialized treatment

Diagnosis/Cause Identification

Practitioner and Practitioner and staff clarify staff clarify known causes known causes of a resident’s of a resident’s heart failure, or heart failure, or seek causes if seek causes if not identified.not identified.

Is a work-up appropriate?

with terminal/end with terminal/end stage conditionsstage conditions

if it would not if it would not change change managementmanagement

in a resident that in a resident that refuses refuses treatmenttreatment

if burden of the if burden of the work-up is work-up is greater than greater than the benefit of the benefit of the treatmentthe treatment

if causes are if causes are reversiblereversible

What’s in a work-up?

History/examHistory/exam Lab testsLab tests Chest x-rayChest x-ray EKGEKG

All look for All look for reversible reversible causes of CHFcauses of CHF

Treatment/Problem Management

Heart failure treatment:Heart failure treatment:

Based on established Based on established recommendations (i.e. best recommendations (i.e. best practice/http://www.acc.org)practice/http://www.acc.org)

Consistent with resident choices, Consistent with resident choices, values overall condition, and values overall condition, and prognosis.prognosis.

Establish goals Prolong lifeProlong life

Prevent Prevent worseningworsening

Improve quality Improve quality of lifeof life

Provide comfort Provide comfort carecare

Treatment/Problem Management

Did the staff and practitioner Did the staff and practitioner treat contributing factors and treat contributing factors and

underlying causes of heart underlying causes of heart failure?failure?

Like what??

ArrhythmiaArrhythmia Pulmonary embolismPulmonary embolism Accelerated/Accelerated/

malignant malignant hypertensionhypertension

Thyroid diseaseThyroid disease Valvular heart Valvular heart

diseasedisease

Unstable anginaUnstable angina Fluid volume statusFluid volume status Renal failureRenal failure Medication-induced Medication-induced High salt-intakeHigh salt-intake Severe anemiaSevere anemia

Treatment

Base therapy on the Base therapy on the presence/absence of fluid presence/absence of fluid volume overload, nature of volume overload, nature of dysfunctiondysfunction

Include annual flu and Include annual flu and pneumococcal vaccinationpneumococcal vaccination

Resident’s goals, choices, Resident’s goals, choices, values, are always consideredvalues, are always considered

Consider other relevant interventions

Dietary counselingDietary counseling Diet modificationDiet modification Exercise Exercise Smoking cessationSmoking cessation Address end-stage Address end-stage

HFHF

Monitoring

Implement approaches to Implement approaches to managemanage the individual the individual

with heart failurewith heart failure

Monitoring

Collaboration Collaboration between the between the facility, medical facility, medical director, and director, and practitionerpractitioner

Evaluation and Documentation Document assessment of heart Document assessment of heart

function - any complications?function - any complications? Evaluate and document Evaluate and document

reasons why a resident failed reasons why a resident failed to achieve cardiac/functional to achieve cardiac/functional goalsgoals

Review medication regime and Review medication regime and modify as neededmodify as needed

Monitoring

ComplicationsComplications in in an effort to an effort to “treat” heart “treat” heart failure can occur.failure can occur.

Bibliography

AMDA Clinical Practice Guideline – Heart Failure, 2002AMDA Clinical Practice Guideline – Heart Failure, 2002

Aquilani, R, et. al. Is nutritional intake adequate in chronic Aquilani, R, et. al. Is nutritional intake adequate in chronic heart failure patients? Journal of the American College of heart failure patients? Journal of the American College of Cardiology. 2002 (Vol. 2) (7)Cardiology. 2002 (Vol. 2) (7)

Carboral, M.F. Putting the 2005 American College of Carboral, M.F. Putting the 2005 American College of Cardiology/American heart failure association heart failure Cardiology/American heart failure association heart failure guideline into clinical practice: advice for advance practice guideline into clinical practice: advice for advance practice nurses. Retrieved June 30, 2006 from http:// www. nurses. Retrieved June 30, 2006 from http:// www. Medscape .com/view article/533626Medscape .com/view article/533626

Bibliography

Ferris, Mara. Geriatric Emergency Assessment & Ferris, Mara. Geriatric Emergency Assessment & Prevention. 2002; PESI, Eau Clare, WI.Prevention. 2002; PESI, Eau Clare, WI.

Steefel, Lorraine, RN, MSN. New Advances Offer Steefel, Lorraine, RN, MSN. New Advances Offer Hope for Treating Heart Failure. Hope for Treating Heart Failure. Nursing Nursing Spectrum, Spectrum, March 2004; pp12-13.March 2004; pp12-13.