- The document provides instructions for viewing a recorded education session on heart failure and inotrope therapy. It includes links to download presentation materials and references to print before viewing. - Participants are asked to copy the web addresses into their browser to access and print a slide presentation handout, 4-day process flow chart, and patient assessment guide. - The session will cover heart failure background, inotrope therapy indications and goals, pharmacy and home health agency responsibilities, and discharge planning over 4 days.

1. 4/14/ 201 3
Welcome
Before viewing the recorded session, please access the files below
and print the documents to use as a reference during the
presentation.
Home Health Agency (HHA)
Because this is a recorded session, you will not be able to click Heart Failure & Inotrope Therapy
directly on the links. You will need to copy each address and enter it
into your browser in order to open each document. You should Education Module
print all three documents.
• http://tinyurl.com/d32aw6t (Slide Presentation Handout)
• http://tinvurl.comiczyfIg4 (4-Day Process Flow) Jodie Lockman-Samkowiak, MSN RN CRNI
Doctor of Nursing Practice Student
• http://tinvurl.com/d9dvbnb (Patient Assessment Guide) Madonna University
• The planners and faculty have declared no
conflict of interest.
Heart Failure Background
• Completion of the entire webinar and the
evaluation is required to obtain contact hours
for this event.
Heart Failure The Problem Objectives
The participant will be able to :
• The American Heart Association estimates:
• Describe the clinical presentation of advanced left ventricular systolic
(LVS) heart failure (HF) in adults.
• 5.8 million Americans have HF with 670,000 • Describe the comprehensive management plan for the patient with
advanced LVS HF.
new HF cases diagnosed annually • Provide patient and caregiver education for home inotrope therapy
• $34.4 billion in healthcare services, • Demonstrate infusion-related care and safety of the patient receiving
medications, and lost productivity inotrope therapy in the home setting.
• Identify pharmacy, home health care nurse, patient and caregiver
• The majority of this cost is in the late stages responsibilities and roles.
of heart failure • Describe the goals of home inotrope therapy.
• Over 20% of discharged patients are o improve overall blood flow
readmitted within 30 days o Increase organ perfusion
o Reduce symptoms
• Describe the infusion-related care and safety of the patient receiving
inotrope therapy in the home setting.
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2. 4/14/2013
Heart Failure Defined
Transitional Care
• 19.6 % of Medicare patients are readmitted within 30 Heart failure (HF) is generally defined as a
days of original discharge
• A large number of re-admissions are avoidable chronic disease characterized by the inability
• High readmissions = financial penalties for hospitals of the heart to pump an adequate amount of
blood, to achieve the demand of the different
organ systems, and/or doing so at increased
filling pressures.
Nasd m, Ala.. A CcogeseveHeart Failure a. Public Health www kw, ecisiftne0/epidtsioimpl.639/ConglleartFail.or
Heart Failure Clinical Presentation
The Remodeled Heart
• Decreased exercise tolerance
• Fluid retention Healthy Heart Remodeled Heart
• Need to sleep with more pillows or in recliner
• Arrhythmias
• No symptoms of HF, but are found to have evidence
of cardiac enlargement or dysfunction during
evaluation
Jessup M, Alsra.ns MT, Casey Of , Feldman AM, Francis GS, Genies Te, itonstarn MA, Mancini DM, Ratko PS, Silver MA, Stevenson
LW, Tancy CW, 2[103 focused update: ACCF/ AMA Guidelines for the Diagnosis and Management of .art Failure in Multi:a report or
the Arnerican College of Cardiology Foundation/American klean Association Task Force on Practice Guidelines:developed in
National Heart, Lung & Blood Institute, US
collaboration with the InMmational Society for Haan and Lung Transplantation,Circulation 200.3,119(14),1977.2016. Dept. Health & Human Services,
National Institutes of Health
Classifications/Stages
Heart Failure Types
New York Heart Association American College of
(NYHA) Functional Cardiology/American Heart
Systolic heart failure Diastolic heart failure Classification Association (ACC/AHA) stages
Depressed ejection fraction Preserved ejection fraction
• Class I: no limitation of activities; no • Stage A: High risk for HF, no structural
symptoms from ordinary activities heart disease or symptoms
• Class II: slight, mild limitation of • Stage & Heart disease with asymptomatic
activity; comfortable with rest or with left ventricular dysfunction
mild exertion.
Ejection fraction(En • Stage Prior or current symptoms of HF,
known structural heart disease, shortness
A measurement of the amount of blood pumped out Class III: marked limitation of activity; of breath, fatigue, & reduced exercise
comfortable only at rest. tolerance
of the left ventricle with each heartbeat.
Class IV: should be at complete rest, • Stage!): Refractory end stage HF, marked
confined to bed or chair; any physical symptoms of HF at rest despite maximal
activity brings discomfort, symptoms medical therapy, e.g. those who are
Occur at rest. recurrently hospitalized or cannot be safely
discharged from the hospital without
specialized interventions
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3. 4/14/2013
Treatment of Heart Failure
AHA Get with The Guidelines International Guidelines are similar
o Remove precipitating or exacerbating factors
o Lifestyle modifications
o First line drug therapy:
• Angiotensin Converting Enzyme (ACE) inhibitors + Angiotensin II
Receptor Blockers (ARBs) decrease blood pressure and improve blood
flow from the heart to the vessels Advanced Heart Failure
• Beta blockers
• Spironolactone and eplerenone
• Loop diuretics
— Treatment of sleep apnea
— Treat atrial fibrillation
— Anticoagulation
— Exercise Training
httro//www..artorg/HFARTORG/Healthcarenesearch/rtert,thahertuidelinesHaStrokeirtetWitrtrheenidelinesHeartealloreHornenage
irereet-Fir_OCNI307433_SubHomenane,ian
=man, Ober Mehra, 2010. Chronic Heart Hinge: contemporary diagnosis and management Moyo <folk Ploceedings.85121, 180-
A Word About VADs
Treatment of Advanced HF An internal heart pump placed to help Opportunities with VADs
blood pump through the lungs and back • Inotrope bridge
out to the body. A cardiologist may use • Anti-infectives
Device Therapy inotropes, VADs or both • IVIG (transplant)
• Cardiac resynchronization therapy (CRT) 0
• Implantable cardioverter-defibrillator (ICD) "
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Infusion Nurses Society(INS)
Standards of Practice
• INS is the global authority on infusion nursing
• Foundation in evidence-based research
Inotrope Therapy • Should be the basis of all agency infusion
related policies and procedures.
• INS web site has a multitude of publications
www.insl.org
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4. 4/14/2013
Inotropes are indicated for the Treatment of Indications for Inotrope Therapy
Refractory Heart Failure (Stage D)
• Short-term therapy for acute management of decompensation
• Bridge to transplantation
• Palliative end of life care
"These individuals represent the most advanced stage of heart
• Inotrope therapy purpose is to:
failure and should be considered for specialized treatment c improve overall blood flow
c. Increase organ perfusion
strategies, such as mechanical circulatory support, o Reduce symptoms and improve the patient's quality of life
continuous intravenous positive inotropic therapy, referral for • The goals of a home inotrope program are to:
o Decrease HE exacerbations
cardiac transplantation, or hospice care."
• Decrease ER visits
o Decrease hospitalizations
Source:
Mesas le, Abraham WT,Cesey DC Feldman MA, Panes GS, Ganiats TG, esestarn Men Mancini DM, SM. PS, Silver Me, Stevenson
LW, tansy CPC POPP focused update. ACCFP1He Guidelines for the Diagnosis and Management of Heart Failure in Mulls: a report of
Me American Cole', of Cangiology ForindMn/American Heart Association Task Some on Practice Guidelines. developed in
LOR.O.01,111ith the International Society foe Heart and Lung Trermiranorion. Circulation 2009.119114):1977.2016. Stevenson 50 Clinical use of mourner therapy . heart failure. ng rd 2 Pan II:Chronic inotrepic Merest.
Circulation 2003; 108. 092-497
Inotrope Drugs Risk/Benefit of Inotropic Infusion
• Dopamine is rarely used in home infusion
• Dobutamine and milrinone are common Positives N egatives
— Milrinone preferred with beta-blockers • Catheter related
• D5W is typical diluent due to sodium restrictions • Enables discharge from bloodstream infections
hospital
• Increase in mortality
• Improves quality of life
• Burden on family
• Fewer rehospitalizations
• increase contractility • Increase dysrhythmias
• improved ventricular relaxation • Drug tolerance/decreased
• increases vasodilation effectiveness
• increase mortality
Gonseesti EZ,Chu EC, Reese 15 Shishehbor PAH, Hsieh E, Sterling RC. Prognosison chronic. Polautamine or ,,'snore infusions . stage Cr
heart Whim. Um Heart Fail. 2109; 2:3206. there sere no mortality differences between chronic intravenous dobutarnine or milrinone in
W iens with stage 0 heart railure being discharged from the hospital. The high mortality in this group seetted M inorroPeclePentence
warrants careful consideration of all options and priorities for further care.
Phermaty HOMe Health Agency
Responsibilities
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5. 4/14/2013
Pharmacy Home Health Agency
Pharmacy Home Health Agency
Responsibilities Inotrope Patient Discharge Planning : Day 2 Responsibilities
Responsibilities Inotrope Patient Discharge Planning : Day 3 Responsibilities
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Home Health Agency
Pharmacy
Responsibilities
Inotrope Patient Ongoing Care and Collaboration
Responsibilities
Home Inotrope Infusion Program
• Why Home?
patient refillassessT m o Decreased infection
• =arre nO r!:;la:resuits
a ttrn
memento emdian
o Decreased costs
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- tt o Improved quality of life
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Mart Wine. roomer of Heart and Lung TranSPlar , , nisi, topzaapT.
Fried, T 0014 Redefining the 'Omni, in advance are planning: oreoadrte for enrol life decision making. Annals of
Internal Medicine,153(6), 256-261.
Patient Selection and Qualification Home Inotrope Therapy Program
Appropriate Patient Selection Medicare Part B Qualification • Drug Therapy - Milrinone - most common
• Patient is clinically stable on • Dyspnea at rest or mild exertion inotrope therapy
current dose of isotropic prior to inotropes with • Loading dose: 50mcg/kg
therapy improvement following initiation
of therapy • Adult dose
• Central venous access
established • Hemodynamic monitoring to
• Stable fluid and electrolyte show improvement of 20% in Infusion rate Total daily dose (24 hr)
balance cardiac index and reduced left Minimum 0.375 mcg/kg/min 0.54 mg/kg
• Home environment (phone, . ventricular and diastolic pressure
Standard 0.50 mc / :/min 0.72 m• /k
environment safe, water, • Able to be monitored regularly by
emergency services available) MD Maximum 0.75 mcg/kg/min 1.08 mg/kg
• Patient/care partner willing to • On digoxin, diuretics, vasodilators
learn without response (can do letter
• Compliance of medical necessity) • Continuous infusion via pump at a prescribed rate
• Reimbursement criteria met • Specific dosage ranges
5

6. 4/14/2013
Home Inotrope Infusion Program Home Inotrope Infusion Program
• Drug Therapy - Dobutamine • Drug Therapy — Dopamine
• Loading dose: none
• Loading Dose: ?
• Adult dose
• Adult and Pediatric Dose
Infusion rate Total daily dose (24 hr)
Minimum 1 mc• /k•/min 1.44 m /k
Standard 2-20 me: /k: /min 2.88 — 28.8 m:/
Maximum 40 mc /k /min 57.6 m:/
• Continuous infusion via pump at the prescribed rate
Fpocranes com
Home Safety Considerations
• Two pumps always available in the home
Special Concerns:
• Regular change of batteries • Do not flush the continuous inotrope IV line without a
o Do not allow batteries to be completely drained physician's order
• Refill of drugs delivered prior to last bag being used • If intermittent: flush line slowly to avoid bolus of inotrope
• Instruct to place back up pump on patient first; then reset
• Use of thrombolytic drugs to dissolve clots within the venous
other pump.
access device
• Instruct to rotate bags of medication to prevent expiration.
• Peripheral IV order available • Always have an extra bag in the home
• Phone availability • Assess need for IV diuretic (notify MD of continuous weight
• 911 emergency availability gain not responding to oral diuretics). 2 pounds/wk
• Notify MD/pharmacy of 5 lb weight gain in 24-48 hours
• Notify MD/pharmacy of increase in resting pulse of 30 or
more
(Gautman, Uber, Mehra, (2010). Chronic Heart Failure: Contemporary diagnosis and
management. Mayo Clinic Proceedings,85(2), 180-1951
Typical Inotrope Therapy Supplies Provided by Home Health Care Visit Frequency
Home Infusion Pharmacy
Front-Load visits to concentrate on teaching and verification
Educational materials of understanding. Example:
Extra medication bags in the refrigerator (with tubing connected) • Week 1— Daily Visits
Extra programmed pump • Week 2— Every Other Day Visits
Pump batteries • Week 3 — 2 times per week
Extra pump tubing • Week 4— Weekly and as needed
Sterile alcohol pads
• Do not decrease visit frequency if patient/caregiver
Extension sets
understanding and compliance is questionable.
Needleless caps
• Increase visit frequency if changes in dose/regimen changes
Sterile central line dressing kits
Non-coring needles (if patient has a port) • Increase visit frequency if changes in critical parameters occur
Saline flushes • 1 X per week visit frequency is minimum when stable on
Heparin flushes home inotrope therapy
Tape
6

7. 4/14/2013
Typical Lab Tests Ongoing Monitoring Requirements
Assess With Each Visit and Report Changes in:
• Creatinine
• Vital signs
• Compete Blood Count (CBC) • Central Line Complications
• Urinalysis • Heart rhythm
• Pain assessment (including chest pain)
• Electrolytes
• Weight
• Liver Function • Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
• Edema
• Lung sounds (rates)
• Ascites
• Hepatomegaly
• Dizziness
• Confusion
• Depression
What if the inotropic drug dose has
Critical Parameters/Assessment
been changed?
It is important that the home care nurse increase visit
This document is to be used in the home care nurse as an assessment guide to assure all aspects of
frequency when there is a dose change if seeing the patient pollen therapy and tare one addressed during a home health visit or telephone aSSeSSIMMI. The nurse
infrequently such as weekly. An example: should document against all of the following each home care v isit and each telephcae assessment with
the patient caregiver Phrsieiam must be notified when assemsment mulls are diatilie Ar101.11491IPS,
• Increase visits to every other day X 1 week then resume Tke failowim, art ahe pardon...vs sedan
previous schedule once stable on new dose.
Patient •ame DOB;
Acceptable Par=mrs per Dr.
Assess for changes in: (Report variances ia parameters to bath pharmacy and physician)
Weight Gal of: pounds in hours
• Blood pressure
B/P Outside a( Rasp: Sastolic: Diastolic
• Pulse pressure (narrower) Poise: or
• Changes in circulation: Tampers...re: Report temperature f
• Pallor taide.M.Yynniakaowdn non...Lean!.
• Dizziness
• Mental status changes
• Pulmonary changes
Home Visit
• Use the Home Motrope Therapy Patient Assessment Guide! Patient/Caregiver Education:
• Verify accuracy and appropriateness of inotrope therapy following the 5
Rights:
• Infection control
• Right Patient • Intended therapeutic effects
• Right Drug
• Appropriate storage and handling of medication
• Right Dose
• Right Route • Inotropic therapy administration
• Right Time • Pump operation, alarms and troubleshooting
• With inotrope therapy it is important to verify the drug
• Emergency plan for interruption in therapy
• Concentration
• solution (diluent)
• Volume
Paeo e• we
• Verify pump settings/rate of administration
• CVAD assessment/care Edolc•..dceic,fri
• Draw lab specimens peripherally if possible
• Reinforce essential patient teaching
7

8. 4/14/2013
Home Patient Education Patient/Caregiver Education (cont.)
• Adherence to medical regimen
• Medication side effects • Signs and symptoms of worsening heart failure
• Signs and symptoms of infections • Care, maintenance, and safety of central line
• Signs and symptoms of worsening heart failure • Signs and symptoms of CVAD complications
• Self-monitoring (e.g. daily weights. temperature) • Signs and symptoms of severe side effects/adverse drug
reaction
• Low sodium diet
• Adverse effects of inotrope therapy
• Fluid restrictions
• Diet (low sodium / low fat) and fluid restrictions
• IV site care, infection control
• Monitor and record daily:
• Make healthcare team aware of changes in insurance
— Vital signs (BP, Pulse, Temp)
• Ongoing confirmation of compliance is critical
— Weight
Central Line Assessment Teaching Additional Patient Assessment:
Central line infection is common • Activity level and ability to perform ADLs
reason for rehospitalization
• Loss of energy
especially after decrease in
home health visit frequency • Is the patient/caregiver self-monitoring and implementing:
Sterile technique must be — Behavior changes
maintained by patient/caregiver — Daily weight monitoring
for all central line accessing and
— Adherence to diet
bag changes.
— Symptom management methods
Ongoing verification of
compliance with sterile — Smoking cessation
technique is necessary even — Avoiding unsupervised use of NSAIDS
after patient/caregiver has
Medication compliance
demonstrated independence
Additional Patient Assessment (cont.): Continuous Inotrope Infusion:
• Remove medication bag with connected tubing from refrigerator
• Gather supplies (extra pump with new batteries)
• Turn pump on and verify settings
• Connect to pump
• Prime tubing per manufacturer's manual
• Assess diet compliance (low salt/low fat) • Stop the pump that is on the patient
• Changes in health status that suggest worsening heart failure • Disconnect old tubing and pump from patient
• Changes in health status that suggest decline in renal function • Cleanse needleless connector vigorously with sterile alcohol pad
• Drug interactions: • Connect new tubing and pump to patient
— Inotropes require a dedicated line and no other IV drugs should • Press START button on new pump and verify infusion
be given through that line. • Disconnect tubing from old pump
— Imipenem (primaxin) • Reset old pump so that it is ready to use if needed
— Antihypertensives (potentiated by milrinone) • Turn off old pump
— Diuretics (may necessitate a reduction in dose) • Change batteries in old pump
8

9. 4/14/2013
Intermittent Inotrope Therapy Ongoing Assessment
• Obtain baseline vital signs prior to infusion
• Remove medication bag with connected tubing from refrigerator • Ability of caregiver to follow technique and instructions
• Gather supplies (extra pump with new batteries) ongoing for inotrope bag changes, oral medication therapy
• Turn pump on and verify settings and CVAD management.
• Connect to pump
• Assess need for increase in home health care visits
• Prime tubing per manufacturers manual
• Cleanse needleless connector vigorously with new sterile alcohol pad each • Recommend telephoning patients between visits when initial
time before connecting syringe or tubing. decrease in visit frequency occurs.
• Flush CVAD with 10m1 saline
• Connect tubing
• Press START
• Repeat vital signs every 10-15 minutes % 1 hour after infusion begins
• At end of infusion, disconnect tubing and flush CVAD SLOWLY with 10m1 of
saline followed by ordered heparin flush.
• Turn off pump and reset (change batteries as directed).
Documentation Remember...
• Standing orders for anaphylaxis treatment
• Medication: • Communication is key to the success of inotropic therapy
— Name
• Pharmacy is on call 24/7
— Dose
— Diluent volume • Pharmacy number is on all medication labels and on folder
— Concentration that arrives with the initial supply delivery
— Rate of infusion • Assure that patient has pharmacy phone number at fingertips
• Pump settings:
• Collaborate with physician AND pharmacy, patient/caregiver.
— ml/hr
— Before and after container/bag change if applicable
• Procedures and medication administration performed
• Patient teaching done
• Observation of return demonstration
• Response/understanding of information taught (teach-back)
Survey Link
• This is a recorded session. You will not be able to
click this link directly.
• Please copy or write down this URL and type it in
your internet browser to access the survey.
• Completion of the survey is necessary in order to
receive your continuing education credits.
• If you have further questions related to patient-related care, contact
designated infusion pharmacy providing services for your particular patient.
http://tinyurl.com/cat3bdy
• For questions related to this presentation, I can be reached at
jlockmansamkowiak@my.madonna.edu
1