REDUCING HEART FAILURE HOSPITAL READMISSIONS: ARE YOU PREPARED? Lois Ustanko, RN, MHA Director of Health Ministries, Sanford Health Fargo Victoria Teske, MS GNP-BC Assistant Professor Minnesota State University Moorhead Nurse Practitioner Long Term Care Sanford Health GERO Nursing Conference April 11, 2014
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Reducing Heart Failure Hospital Readmissions: Are You Prepared?
Reducing Heart Failure Hospital Readmissions: Are You Prepared?. Lois Ustanko , RN, MHA Director of Health Ministries, Sanford Health Fargo Victoria Teske, MS GNP-BC Assistant Professor Minnesota State University Moorhead Nurse Practitioner Long Term Care Sanford Health - PowerPoint PPT Presentation
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REDUCING HEART FAILURE HOSPITAL READMISSIONS:
ARE YOU PREPARED?Lois Ustanko, RN, MHA
Director of Health Ministries, Sanford Health Fargo
Victoria Teske, MS GNP-BCAssistant Professor
Minnesota State University MoorheadNurse Practitioner Long Term Care
Sanford Health
GERO Nursing ConferenceApril 11, 2014
Behavioral Objectives1. Describe a community-based approach to improve
coordination between care settings.2. Identify best practices that can be implemented to reduce
avoidable hospital readmissions.3. Describe the physiology and pathophysiology of heart failure.4. Discuss the clinical assessment and classifications of the
patient with heart failure.5. Discuss the indications, dosing, adverse effects, and
monitoring of drugs used to manage heart failure.6. Formulate effective teaching plans for patients with heart
failure and their family members.
Why is this important?
HospitalTransitional
SNF
ER
Home
Assisted Living
Nursing Home
Death
23%
35% 19%
20%
Source: AHCA
Boomers fear a medically intrusive dying process Communication among patients, their families,
and health care providers is often lacking Nurses have continuous contact with patients
and families during the last phase of life so have the potential to shift the focus
With the growing number of aging in the U.S. the need for competent end-of-life care increases
Experts Report “Burdensome” CareRetrospective Study of Medicare Beneficiaries Who Died, Mean Age of 82.3 Years
Series1404142434445
% with NH Stay in Last 90 Days of Life
200020052009
Series102468
10
% with Hospice Stay of < 3 Days
200020052009
Series155
60
65
70
% with Hospitalization in Last 90 Days of Life
200020052009
ICU Ventilator0
10
20
30
% with ICU & Ventilation in Last 30 Days of Life
200020052009
Transitions• Mean of 3.1
transitions in last 90 days
• 14.2% experienced a transition in the last 3 days of life
• 11.5% had > 3 hospital stays in last 90 days
Source: Teno et al, 2013
$400
$4500
77 yrs.
Higher Per Capita Spending Doesn’t Translate into Higher Life Expectancy
Hospital Readmissions Reduction Program (HRRP)
Source: 2006 CIA Fact Bookhttp://www.santarosaconsulting.com/santarosateamblog/post/2012/03/29/an-early-look-at-hospital-readmissions-reduction-program
Immediate clinical needs Comprehensive needs of the whole person
Patients as recipients of care Patients and families as essential, active members of the care team
Varity of different teams based on setting of care
Cross continuum teams with a focus on the patient plan over time
Key Areas:1. Patient education with Teach Back2. Multidisciplinary rounds (bedside is best)3. Post discharge follow up-medical homes4. Early follow up-timely appointments5. Medication reconciliation6. Proactive thinking-treat symptoms early
Cross-Continuum Team Collaboration
Key Elements
Health Information Exchange & Shared Care Plans
Patient and Family Engagement
Identify those at risk Case reviewsNursing competencies
Medication reconciliation S-BAR for status change reportsNursing home capabilities Access to the EMRTelehealth Shared CHF patient education materials
Advance care planning Medical homes
INTERACT
Communication Tools
Decision Support
Tools
Advance Care
Planning Tools
Quality Improvemen
t Tools
Go tohttp://www.interact2.net/tools.html
Signs of Transition to End-Stage HFEnd-of-life care should be considered in patients who have symptoms at rest despite repeated attempts to optimize pharmacologic, cardiac device, and other therapies, as evidenced by 1 or more of the following: Multiple hospital admissions. Chronic poor quality of life with minimal or
no ability to accomplish activities of daily living.
Multiple implantable defibrillator shocks. Inability to control the heart failure with
standard medications. Need for continuous intravenous inotropic
therapy support to increase myocardial contractility.
Heart Failure Society of America
Heart Failure is a Chronic, Progressive Illness
Patients with heart failure report high symptom burden, including• Pain• Anxiety• Shortness of breath
Mortality rates can be as high as 30% once the patient presents to the ER multiple times.
MAR 2011 JUN 2011 SEP 2011 DEC 2011 MAR 2012 JUN 2012 SEP 2012 DEC 2012 MAR 2013 JUN 201310%
Left HF, COPD (cor pulmonale), PE, RV infarction, pulmonary HTN
PathophysiologyOutput of RV < venous return → venous congestion and decreased output to lungs
Causes MI, HTN, AR, AS, cardiomyopathy
PathophysiologyDecreased cardiac output
Right and Left Heart Failure Symptoms
Decreased cardiac output from left ventricle →
Increased preload left heart →
Increased pressure in pulmonary vascular system →
Fluid moves from pulmonary capillaries into lung tissue → impaired diffusion of oxygen and carbon dioxide
Pathophysiology of Respiratory Manifestations
Dyspnea◦ Ask many questions◦ Any activities you’ve stopped doing? Any
modifications by caregiver? Cough Orthopnea Paroxysmal Nocturnal Dyspnea Dyspnea on exertion (DOE)
Respiratory Symptoms
Class Patient SymptomsClass I (Mild) No limitation of physical activity.
Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea
Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea
Class III (Moderate) Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea
Class IV (Severe) Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
NYHA Classification of Heart Failure
Inspection◦ Respiratory rate◦ Use of accessory muscles
Auscultation Percussion O2 saturation Mentation Decline in function/self compensation
Respiratory Assessment
Crackles
Crackle 1 Crackle 2 Crackle 3
Continuous, high pitched, musical sound, almost a whistle
During inspiration or expiration Caused by high velocity air flow through
narrowed airway
Wheezes
Wheezes 1 Wheezes 2
Heart Failure- bibasilar crackles (can disappear with continuous exaggerated respiration), sounds with pleural effusion, wheezing
Lobar Pneumonia –crackles over one involved lobe, breath sounds
Asthma – scattered wheezes Pneumothorax – decreased or absent
breath sounds COPD – generally decreased or absent,
wheezes
Common Pulmonary Auscultation Abnormalities
Assesses underlying tissue◦ Bilaterally◦ Superior to inferior
◦ Heard best with bell Ventricular gallop Myocardial failure, volume
overload
Occurs During Diastole◦ Marks atrial contraction◦ Immediately precedes
S1◦ Heard best with the bell
Etiology – increased resistance to ventricular filling following atrial contraction
Hypertensive heart disease, CAD, cardiomyopathy
Produced by turbulent blood flow◦ Across partial obstruction◦ Increased blood flow through normal
structure◦ Flow into dilated chamber◦ Across stenotic or regurgitant valves◦ Shunting through abnormal passage
A systolic murmur of aortic stenosis
Cardiac Murmurs
Jugular Venous Pressure (Distension)
Jugular Venous Distension (JVD) Identify external
(center of clavicle to angle of jaw) and internal (below sternocleidomastoid) jugular veins
Identify sternal angle Elevate head @30-45
degrees Measure in cm distance
from sternal angle to top of distended vein (vertically)
Add to 5. Normal is 0-9 cm
Measurement of R CHF or fluid overload Bed at 30 degrees Press firmly on RUQ for 30-60 seconds Observe for increase in JVP > 1 cm rise is abnormal as heart can not
handle increase in venous return
Hepatojugular Reflux HJR)
Decreased blood supply leads to anorexia, N/V, slow digestion
Tenderness Protuberant abdomen Dullness to percussion Fluid wave
Gastrointesinal Assessment
Increase in capillary pressure Other causes include ↓ serum albumin, renal
disease, dependent position (resolves during the night)
Peripheral, sacral, scrotal, gastrointestinal tract Associated color changes Bilateral or unilateral
◦ 1+ Slight Pitting, no distortion◦ 2+ Somewhat deeper pit, no readily detectable distortion◦ 3+ Pit is noticeably deep, extremity looks fuller and swollen◦ 4+ Pit is very deep, lasts a while, extremity is grossly
distorted *Mosby, 2002
EDEMA
Peripheral Pulses Color, Capillary Refill Skin Temperature Renal Output Mentation
Assessment of Perfusion
Vasoconstriction leads to: ◦ Cool, clammy or dry skin ◦ Cyanosis ◦ Slow capillary refill ◦ Decreased peripheral pulses
Blood pressure◦ Goal is to reduce afterload and preload◦ Systolic “lowest tolerated” as low as 90 systolic◦ Need to maintain perfusion (head and kidneys)◦ Decreased BP
Hypovolemia?◦ Increased BP
Nonadherence? ↑SNS activity?
Heart rate◦ Stroke volume x heart rate = Cardiac output◦ Too low cardiac output drops◦ Too high, ventricular filling time decreases → ↓ stroke
volume Respiratory rate
Vital Signs
DyspneaCracklesPeripheral Edema
Most Common Clinical Features of Hospitalized Patients in Order (ADHERE, OPTIMIZE-HF)
Signs of hypervolemia may be absent in patients with worsening heart failure Miller, Frana, Rodriquez, Laule-Kilian, Perruchoud (2005)
Increased filling and intravascular pressures may be present before clinical manifestations Stevenson, Perloff (1989)
Multiple hospitalizations for exacerbations risk for ↑ mortality
Medications limited by side effects (*renal function)
Consider quality of life Education of client and support system Plan in place
End of Life
Heart failure is a syndrome that presents with alterations in hemodynamics and maladaptive responses of the sympathetic nervous system
Signs and symptoms include those of diminished cardiac output and tissue congestion
Multiple approaches to assessment are necessary to accurately identify acute decompensation
The medication regimens for heart failure patients are effective but adherence is crucial
Teaching plans should be holistic, consider each clients specific situation
Heart failure exacerbations associated with decreased quality of life, increased mortality therefore addressing palliative and end of life care needs to be addressed following multiple hospitalizations