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Heart Failure by Kismet Rasmusson, FNP-BC, FAHA


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Heart Failure by Kismet Rasmusson, FNP-BC, FAHA
February 2010

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Heart Failure by Kismet Rasmusson, FNP-BC, FAHA

  1. 1. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Heart Failure Transitions in Care Kismet Rasmusson, FNP-BC, FAHA FNP- February 17, 2009 1350g.1 Feb 14-20, 2010 1350g.2 Objectives •To understand the impact heart failure has on healthcare delivery •To learn strategies to provide best practices for heart failure care 1350g.3 1
  2. 2. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Case Study Mr. C is a 68 year old man with cough and shortness of breath whose MD squeezes him in to his busy schedule. He was hospitalized 3 weeks ago with CHF, discharged on captopril and a “no added salt diet,” with encouragement to see his MD in three weeks. His MD does not have information about the hospitalization. On exam, Mr. C is told by his MD he still has “some heart failure,” is encouraged to continue cutting salt out of his diet, and told to call back if he is not better. Two weeks later, Mr. C calls 911 because of severe breathlessness and lower extremity swelling, and is admitted to the hospital. A more complete history in the hospital reveals that he has been taking the captopril only as needed because it seems “strong,” and he has never added salt to his diet, so his diet 1350g.4 has not been changed. Heart Failure Scope of Problem • Most common cause of hospital admission in patients over age 65 years • Accounts for > 1 million hospitalizations/year • Accounts for more than 6 million hospital days/year • Accounts for $37 billion in costs annually in the U.S. • Re-hospitalization or death approximately 50% within 6 months • Median length of stay 5 - 6 days • In-hospital mortality 5 to 8% Thom et al. Circulation 2006 February 14;113(6):e85-151. Felker et al. Am Heart J 2003;145(2):S18-S25. Felker et al. J Card Fail 2004;10:460-466. Lee et al. JAMA 2003;290(19):2581-2587. Hunt SA et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. 2001. Graves EJ, Gillum BS. 1994 Summary: National Hospital Discharge Survey. National Center for Health Statistics; 1996. 1350g.5 Heart Failure … is a serious public health concern … is a substantial cause of morbidity and mortality and health expenditures … evidence-based therapies have been demonstrated evidence- to improve outcomes … requires tremendous efforts of care across the continuum 1350g.6 2
  3. 3. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Heart Failure Hospitalizations 70% due to worsening chronic HF With either preserved or reduced LVEF (46-54%) (46- 25% due to de novo HF 5% due to advanced HF Refractory to therapy Severe LV systolic dysfunction Low- Low-output state Mean age 73 years Age > 75 years in 50% of admissions 52% female Georghiade. Circulation 2005;112:3958-3968 Adams. Am Heart J 2005;149:209-216 1350g.7 Age-Adjusted Heart Failure Hospitalization Rate National Hospital Discharge Survey, 1979-2004 1200 1000 HF Diagnosis Listed 800 000 Men 1st Per 100,0 Women 1st 600 Men 2nd+ 400 Women 2nd+ 200 0 1979 1984 1989 1994 1999 2004 Fang et al. J Am Coll Cardiol 2008;52:428-434 1350g.8 Comorbidities in Patients With HF 45 42 40 35 31 32 28 30 ents (%) 25 20 18 Patie 20 15 14 15 11 10 6 3 3 5 0 Fonarow et al. Arch Intern Med. 2007;167:1493−1502. Abraham et al. J Am Coll Cardiol 2008;52:347-356. The OPTIMIZE-HF Registry [database]. Final Data Report, Duke Clinical Research Institute, July 2005. 1350g.9 3
  4. 4. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Heart Failure Hospitalization Rate National Hospital Discharge Survey, 1979-2004 4000 3500 3000 000 2500 Men < 65 Yrs Per 100,0 Men > 74 Yrs 2000 Women < 65 Yrs 1500 Women > 74 Yrs 1000 500 0 1979 2004 Fang et al. J Am Coll Cardiol 2008;52:428-434 1350g.10 LVEF in Hospitalized HF Patients 5,000 Documented LVEF Measured Prior to or During Hospitalization 4,183 15,215/36,115 (42%) with LVEF > 40% 4,000 3,814 3,506 3,193 Patients (n) 2,924 2,947 3,000 2,812 2,806 s 2,345 2,331 2,000 1,833 1,270 1,137 1,000 553 274 44 100 32 10 1 0 0- 6- 11- 16- 21- 26- 31- 36- 41- 46- 51- 56- 61- 66- 71- 76- 81- 86- 91- 96- 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 Left Ventricular Ejection Fraction (%) Fonarow GC, et al. J Am Coll Cardiol. 2007;50:768−777. 1350g.11 Outcomes P=NS 7 6.0 5.7 6 P=NS P<.0001 5 4.0 4.0 3.9 4 2.9 LVSD 3 2 PSF 1 0 Length of Stay, Length of Stay, In-Hospital Mortality Mean (days) Median (days) (%) PSF = LVEF ≥40%; Fonarow GC, et al. J Am Coll Cardiol. 2007;50:768−777. 1350g.12 4
  5. 5. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) STAGES OF HEART FAILURE *ACCF/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. 2009 Stage A Stage B Stage C Stage D IDENTIFYING EACH STAGE…. • High blood pressure • Prior heart attack • Known heart failure • Marked symptoms • Atherosclerosis • Evidence of enlarged • Known symptoms: despite optimal • Diabetes or thickened heart Shortness of breath therapies • Obesity • Valve disease Fatigue, reduced • High cholesterol activity tolerance • Sedentary lifestyle • Family history of cardiomyopathy • Use of cardiotoxins • Continue stages TREATING EACH STAGE…. A, B • Continue stages A, B, • ACE-I or ARB and C • Treat high BP • Continue stage A • Beta-blockers • IV inotropes • Smoking cessation • Start medications: • Diuretics • Nesiritide • Treat lipid disorders ACE-I or ARB • Spironolactone • Heart transplantation • Exercise Beta-blockers • Digitalis • Mechanical devices: • Treat diabetes • Internal cardiovertor • Hydralazine/ISDN LVAD • Avoid illicit drugs defibrillator • Biventricular pacing • Hospice care • Limit excess alcohol +/- defibrillator 1350g.13 The Course of Heart Failure Complete Care = Heart Failure Care + Supportive Care 1350g.14 Goodlin et al, J of Card Fail, Vol 10. 2004 Successful Heart Failure Management 1350g.15 5
  6. 6. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Algorithm for ADHF CONGESTED Goals of Therapy HYPOPERFUSED ↓PCWP and Diurese Unload and ↑SV/CI ↑CO/BP/renal perfusion rales, edema, JVD, S3 mixed presentation low BP, cool, clammu CI/SV adequate d ↑PCWP, ↑PCWP ↓CO ↓CO, ↑↓PCWP Inotropes Diuretics Vasopressors Diuretics & vasodilator Combined therapy Loop bolus Nesiritide Diuretic +/- vasodilator Combo Agents NTG IABP Cont. infusion Nitroprusside Consider Inodilator VAD Ultrafiltration / HD Milrinone, dobutamine Transplant? Compilation of ACC/AHA, HFSA and ESC Guidelines 1350g.16 Mainstay of Heart Failure Management Medical & device therapies proven to reduce symptoms, improve mortality and readmissions… • ACE inhibitors (ARBs) ( ) • Beta blockers • Aldosterone antagonists (spironolactone) • Digoxin • Diuretics • ICDs 1350g.17 1350g.18 6
  7. 7. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Getting the “Congestion” out of Heart Failure Pharmacologic therapy: Diuretics Vasodilators Natriuretic peptides p p Inotropes Avoidance of NSAIDs/COX II and some oral hypoglycemic agents Nonpharmacologic therapy: Sodium and fluid restriction Ultrafiltration Hemodialysis 1350g.19 JCAHO & CMS Heart Failure Core Performance Measures Assess left ventricular function; • prior to admission, during hospitalization, or plan after discharge Prescribe ACEI or ARB for LVEF < 40%; • document contraindications to both, when not prescribed both, Provide discharge instructions: Provide smoking cessation counseling Document Document Document… 1350g.20 Recommendations for the Hospitalized Patient – New Recommendations 2009 Focused Update Recommendations 17. Comprehensive written discharge instructions for all patients with a hospitalization for HF and their caregivers is strongly recommended, with special emphasis on the following 6 aspects of care: - diet discharge medications, with a special focus on adherence, persistence, and - uptitration t recommended d tit ti to d d doses of ACE inhibitor/ARB and BB f i hibit /ARB d medication, - activity level, - follow-up appointments, - daily weight monitoring, and - what to do if HF symptoms worsen. (Level of Evidence: C) 1350g.21 7
  8. 8. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Indications for the Cardiac Resynchronization Therapy Moderate to severe heart failure (NYHA Class III/IV) QRS ≥ 120 ms Right Atrial g LV ejection f ti ≤ j ti fraction Lead 35% Symptomatic despite Left Ventricular stable, optimal medical Lead therapy Right Ventricular Lead 1350g.22 22 Sudden Cardiac Death Heart enlarges Susceptible to cardiac dysrhythmias When sustained VT/ VF, sudden death occurs Internal Cardioverter Defibrillators: Analyze, pace terminate shock lethal arrhythmias reduce mortality ICDs save lives © 2008 Fitzgerald Health Education Associates, Inc. 23 1350g.23 1350g.24 8
  9. 9. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Stage D Heart Failure Therapies LVEF < 25%? Poor toleration of ACEI, ARB and/or Beta blocker? Estimated life expectancy < 2 yrs? Repeated hospitalizations? Progressive symptoms? Poor oxygen consumption? Elevated filling pressures? Requiring escalating diuretics? q g g Consider referral for Consider referral for cardiac transplantation destination LVAD if physiologically <65 yo if physiologically > 65 yo or non-transplant candidate 1350g.25 25 Renlund & Kfoury. 1350g.26 NEJM 2006;355:1922 UTAH Cardiac Transplant Program 1985-2010 @ Intermountain Medical Center Number of Transplants: 1058 1 & 3 year survival: 100% •LDSH/IMED Alive/dead = 50/50 @ 12 years •PCMC Number of publications: >300 Research dollars: >$7,800,000 $ •VAMC Trainees: 57 •UUHSC UNOS certification CMS certified since 1988 JCAHO accredited March 2009:SRTR 1350g.27 9
  10. 10. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) The Utah Artificial Heart Program 1-877-784-2226 Leading center in the US >20 years of experience in artificial heart technologies Multidisciplinary approach Acute, temporary support Bridge to transplantation Destination therapy 1350g.28 End-of-Life Considerations Discuss prognosis and chance of survival Discuss advanced directives, and how this may change with changing clinical status Discuss option of deactivating an ICD Provide continuity of care between inpatient and outpatient Use strategies for palliation of symptoms g p y p Diuretics Inotropes Nitroglycerin Oxygen Anxiolytics Morphine 29 1350g.29 Patient Support Network Utah Artificial Heart Referring Program Administrative Physician Representative Cardiac Community Surgeon Patient Clinical Interventional Research Cardiologist Critical Heart Care Failure Team Team Heart Transplant 1350g.30 10
  11. 11. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Heart Failure at Intermountain Health Care 1350g.31 Intermountain Health Care Heart Failure Prevention and Treatment Program 1350g.32 HFPTP—UTAH Cardiac Transplant—UAHP at Intermountain Medical Center BC Cardiothoracic Surgeons –4 Pharmacists – 6 BC HF/Transplant Cardiologists – 3 Pathologists – 3 BC Intensivists – 4 LCSWs – 1 Nurses CV Anesthesiologists- 6 Anesthesiologists- HF/Transplant Interventional/EP cardiologists- 11 cardiologists- – NPs/PAs – 7 Full diagnositic support (cath/EP/echo) g pp ( ) – Nurse Coordinators – 5 PT/OT/ST Histocompatability & Immunogenetics – MA – 3 Lifeflight – CV Research Coordinators-2 Coordinators- Intermountain Donor Services – HF care manager Financial Specialist UAHP Admin. Support – Nurse Coordinators – 5 – Operations officer – Outreach Nurse Coordinator – 1 – Nurse administrator – Research Nurse – 1 – Director of cardiovascular services – Bio-Engineers – 4 Bio- – Nurse administrator 1350g.33 11
  12. 12. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Intermountain Healthcare’s Cardiovascular Clinical Program Extends HF care throughout the system HF disease management Targeted goals and JCAHO/CMS core measures Provider/nursing HF education – Clinical pearls emailed monthly Cli i l l il d thl Standardized tools – Admission orders, computerized DCM program, standing orders, patient tools, reminders Outcomes monitoring – By provider, unit, hospital, region, system HF Liaisons at each hospital 1350g.34 Institutional Heart Failure Discharge Medication Program Reduces Readmissions and Mortality 100 95 Pre-Intervention (n = 11,038) Post-Intervention (n = 8,045) Treatment Rat (%) 65 HR 0.80 tes P < 0.0001 50 46 HR 0.77 38 P < 0.0001 23 18 0 ACEI Rx Readmissions 1-year Mortality Intermountain Health Care: 10 Hospitals Pre 1/96-12/98 (n = 11,038) to 1/99-3/00 (n = 8,045) Pearson TA. Circulation. 2001;104:II–838. 1350g.35 Intermountain’s Heart Failure Tools Admission orders Discharge orders (computerized) Cardiovascular pharmacists Heart failure care manager Heart failure “liaisons” at each hospital Email updates; readmissions, IV diuretics, EF Reminder tools; sticker, posters Education- Education- CME, Nursing, Clinical Pearls Heart Failure Prevention and Treatment Program; 801-507-4000 801-507- 1350g.36 12
  13. 13. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Pharmacist’s Role Identify heart failure patients Educate physicians, nursing, care managers Monitor for appropriate medication therapy Monitor M it reports for accuracy t f Be creative to meet facilities specific needs 1350g.37 1350g.38 Identify Pts & Track HF Measures List of all admissions Review Dx: Sure bets: HF, CHF, SOB, pleural effusions Could be: CP, syncope, AMI, arrythmias, PE Possibly HF f ti P ibl HF: fatigue, pneumonia, cough i h Review records; chart &/or computerized Review w/ providers if questions Track 4 HF measures Have HF diaries, pt ed manuals, DVD/videos ready Use CV discharge form Care managers and pharmacists Other tools 1350g.39 13
  14. 14. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) HF Heart Failure Primary Dx NO YES ~ Similar Dx that could be ~ Teach MAWDS with packet & video coded HF (i.e. Hypoxia, SOB, ~ Check for ACE/ARB Edema, increasing fatigue or ~ Check Echo ~Teach smoking cessation lethargy) ~ Call dietician & pharmacy for teaching NO YES ~ Document in Tandem, Discharge sheet, and charge sheet, and on karedex ts t’s been done done. ~ Give MAWDS Steps ~ Ask Doctor if HF flyer & teach ~ Document in Tandem, Discharge sheet, and on karedex YES NO ~ Teach MAWDS with video/packet ~ Give MAWDS Steps ~ Get Echo unless one has been done ~ Document in Tandem, ~ ACE or ARB or contraindication Discharge sheet, and on ~ Teach smoking cessation karedex ~ Call pharmacy & dietician ~ Document teaching in Tandem, Discharge sheet, and on karedex 1350g.40 Self-management tools: Diary Patient education manual Video/DVD Website 2008 Classes 1350g.41 HF Education 2002 6 week-outpatient HF self-management curriculum offered to any patient week- self- Pre- Pre-test and post-test given to assess knowledge post- Pre- Pre- and post-class determination of use of health resources (ED or office post- visits, hospitalizations 34 of 37 completed the lecture series Average pre-test score 75% post-test 97% pre- 75%, post- All felt the series improved their understanding of HF 90% reported feeling like they could improve self-management and QOL after self- the lecture series The majority felt the class would help them follow their provider’s treatment plan Patients had fewer ED visits and hospitalizations, and had a slight increase in office visits. Rasmusson et al. J of Card Fail. Aug 2002:8(4),S5. 1350g.42 14
  15. 15. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) MAWDS…makes a difference! 1000 750 500 p=0.027 250 n=523 n=983 0 • 1,506 cases met the JCAHO/CMS eligibility requirements for receiving Discharge Instructions 2002 – 2004. Subjects receiving Discharge Instructions are more likely to be alive 1 year following discharge than those who don’t [Hazard Ratio: 0.79, p-value: 0.027, adjusted for age, gender, severity, los ] Supplement to the Journal of Heart and Lung Transplantation Volume 24, number 2S, S68, 79, February 2005. 1350g.43 Heart Failure Core Measures: An Intermountain Healthcare Analysis showed an: 1. Assess left ventricular function: Incremental 1-year Survival Benefit with 2. Prescribe ACEI or ARB for LVEF < Better Adherence to JCAHO Heart Failure 40%: Core Performance Measures* 3. Provide discharge instructions: 4. Adult smoking cessation •G0: adherence to 0 HF measure •G1: adherence to 1 HF measure •G2: adherence to 2 HF measures •G3: adherence to 3 HF measures Kfoury et al. J of Card Fail. 2008; 14(2)95-102. •G4: adherence to 4 HF measures 1350g.44 Public Reporting on Heart Failure Care 1350g.45 15
  16. 16. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) 1350g.46 Heart Failure Disease Management 1350g.47 Care Gap for Patients with CHF Percent of CHF patients given: Average for all Top 10% of hospitals hospitals reporting in the nationwide US ACE i hibi inhibitor or ARB f l f for left 81% 100% ventricular systolic dysfunction (LVSD) Assessment for left ventricular 81% 95% function (LVF) Discharge instructions 54% 89% Smoking cessation advice/counseling 76% 100% CMS and HQA data from 1/05 through 12/05 1350g.48 16
  17. 17. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) HFSA 2006 Practice Guideline (8.7) Heart Failure Disease M anagem ent Patients recently hospitalized for HF and other patients at high risk should be considered f referral h ld b id d for f l to a com prehensive HF disease m anagem ent program that delivers individualized care. Strength of Evidence = A Adapted from : Adam s KF, Lindenfeld J, et al. HFSA 2006 Com prehensive 1350g.49 Heart Failure G uideline. J Card Fail 2006;12:e1-e122. ACC/AHA HF Guidelines 1350g.50 HF Disease M anagem ent and the Risk of Readm ission 1.1 Ekman Risk 1 Ratio 0.9 0.8 Lasater Stewart Jaarsma 0.7 Rich Rauh Venner Cline 0.6 Naylor Fonarow 0.5 Sum m ary RR = 0.76 (95% CI .68-.87) Sum m ary RR for random ized only = 0.75 (CI = .60-.95) 1350g.51 17
  18. 18. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) HF DM Lessons Learned Success will depend on your structural support Administrative/operational Financial Information technology RNs, d RN advanced practice clinicians, MDs d ti li i i MD Support staff Access to urgent care and to HF specialists Supporting this process Tele- Tele-management and remote monitoring Care manager phone calls, twice in first month post-discharge post- 1350g.52 Summary: Guiding Appropriate Heart Failure Care Identify all patients with heart failure Assess ventricular function Prescribe appropriate medical therapies Include non-pharmacologic therapies non- Ensure appropriate follow up plans been made 1350g.53 Heart Failure Quality Improvement Collect baseline data or use existing data source i.e. collect data with HF nurse, case manager, PharmD, or medical student, etc. Select a champion, appoint a team Develop (adapt) treatment algorithms, preprinted orders, discharge forms Communicate with key departments to get buy-inbuy- Present at grand rounds, lectures, and staff in-services in- present rationale for program and tools review prior successes and failures lead discussion regarding recommendations on protocol improvement Implement program to close gaps in care Repeat cycle frequently (every quarter) = CQI 1350g.54 18
  19. 19. LCAC Presentation (FINAL BMS-SANOFI 10-17-01) Key Elements to Quality Improvement Why Do Some Hospitals Succeed? Access to current and accurate data on treatment and outcomes Have stated goals Administrative support Physician champion, support among clinicians Use of pre-printed orders, care maps pre- Use of data to provide feedback Willingness to modernize, change with the times Bradley EH et al. JAMA. 2001;285:2604–2611. 1350g.55 Resources American Heart Association Heart Failure Society of America American Association of Heart Failure Nurses Intermountain Healthcare 1350g.56 Thank You… 1350g.57 19