HFSA and AAHFN joint position statement: advocating for a full scope of nursing practice and leadership in heart failure. Congestive heart failure (CHF) is a common clinical disorder that results in pulmonary vascular congestion and reduced cardiac output. Where can you walk when you are at home? A nurse-guided patient-centered heart failure education program Diana Lyn Baptiste1,3, Hayley Mark1, Lisa Groff-Paris2, Laura A. Taylor1 1. Circ Heart Fail. A propensity-matched study of the effects of chronic diuretic therapy on mortality and hospitalization in older adults with heart failure. These goals should incorporate functional and cognitive status (Class I; Level of Evidence C). The American College of Cardiology Foundation and the AHA have collaborated with the American Medical Association–Physician Consortium for Performance Improvement (AMA-PCPI) to develop sets of HF performance measures (first in 2005 and updated in 2011).236,237 The purpose of these efforts is to provide process and outcome measures that can be used to improve care for patients with HF. Ancillary Interventions for Patients With HF and SNF Regulations. An observational analysis of 15 459 fee-for-service Medicare beneficiaries aged ≥65 years discharged alive after hospitalization for HF in 2005 and 20067 found 24.1% of patients were discharged to a SNF. Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. Emphasize the importance of reporting a change in symptom status to the healthcare provider to avert hospitalization for symptom management (Class I; Level of Evidence C). Ideally, a set of quality measures for patients with HF in a SNF will include both measures of processes known to influence desirable outcomes for this patient population and measures of outcomes themselves. Clinical role of exercise training in the management of patients with chronic heart failure. This dysfunction occurs in 1 of 2 ways: a weakening of the muscle, resulting in a decrease in the heart’s pumping capacity, or an increased stiffness of the heart muscle so that the heart cannot relax properly while the heart … For residents with stable vital signs, diuresis in the SNF with oral or intravenous diuretic agents is appropriate. Circulation , 139 (10), e56-e528. The American Heart Association and the Heart Failure Society of America make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Assessment includes comparing symptoms with those experienced the prior day (same, better, or worse). Rehospitalizations among patients in the Medicare fee-for-service program [published correction appears in. Rehabilitation patients in whom recovery and discharge to home are anticipated and those with uncertain goals should receive guideline-based care.45,46 Long-term residents, particularly those who are dependent in ≥2 ADLs or who have moderate to severe dementia may be appropriate for SNF HF management without hospitalization. Quality of life in the Canadian Implantable Defibrillator Study (CIDS). Institute for Healthcare Improvement. HF is associated with an elevated resting metabolic rate and catabolic/anabolic imbalance.104 Patients with HF require an additional 3 to 7 kcals/kg/day more than healthy adults and may require ≈20% more protein than healthy adults to meet metabolic demands (minimum 1 g/kg).105. When to call the healthcare provider managing HF or 9-1-1, Nurse; physical and occupational therapists. and (3) How confident are you filling out forms by yourself?206 Questions are scored on a 5-point Likert scale, with higher scores indicating lower health literacy. ‡NHYA class improved for 40% in RALES (Randomized Aldactone Evaluation Study). Precipitants of emergency room visits and acute hospitalization in short-stay Medicare nursing home residents. Cardiac function and skeletal114–117 and respiratory118–120 myopathy all contribute to fatigue and decreased physical exertion capabilities in the HF population. This is particularly relevant to frail HF patients, in whom functional disability is likely to be advanced. New York, NY: McGraw-Hill Professional; 2007. What's your role as Ms. McDonald's nurse? Heart failure. Congestive heart failure is the most common indication for admission to the hospital among older adults. Center for Nursing Excellence, Greater Baltimore Medical Center, MD USA. Deactivating permanent pacemaker in patients with terminal illness: patient autonomy is paramount. Traditionally in SNFs, CNAs are the staff members at the bedside the majority of the time and are integral to detect changes in condition. Regulatory agencies use weight gain as a sign of adequate nutrition, so an increase in weight in a SNF is traditionally viewed as a positive indicator of health. Effects of neuromuscular electrical stimulation of muscles of ambulation in patients with chronic heart failure or COPD: a systematic review of the English-language literature. SNFs should have doughnut magnets on-site available for emergency deactivation if needed. Common Factors Contributing to HF Exacerbations in Older Adults. One, the “rehabilitation group,” includes patients recently discharged from the hospital (with any diagnosis) with the goal to recover independent function and return to their prior residence after several weeks of skilled care. This conversation should include preferences for hospitalization in the event of HF decompensation. This updated measure set addresses both in-hospital care and continuing care in the outpatient setting. Philadelphia, PA: Lippincott Williams and Wilkins; 2008. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Diuretics act on the kidneys, causing water, sodium, potassium, or other electrolytes to be lost, depending on where in the kidney the diuretic is working. The healthcare provider managing the resident in the SNF should document HF diagnosis, LVEF, and pathogenesis. Unadjusted postdischarge all-cause mortality was markedly higher for HF patients discharged to SNFs than for HF patients discharged elsewhere, with a 30-day mortality rate of 14.4% versus 4.1% and 1-year mortality rates of 53.5% versus 29.1%, respectively (P for both, <0.0001). CNA indicates certified nursing assistant; HF, heart failure; SNF, skilled nursing facility; and STNA, state-tested ursing assistant. Effect of resistance training on physical disability in chronic heart failure. In this context, selection of specific pharmacological agents should involve consideration of whether the beneficial effects are aimed at modifying the natural history of HF, alleviating symptoms, or a combination of both. Approximately 5 million people in the United States have heart failure and more than 500,000 are diagnosed each year. Residents’ rehabilitation potential, overall status, and goals of care should determine whether they are to be hospitalized if initial diuresis does not succeed in the SNF. Nurses’s knowledge of heart failure education principles. The heart failure and sodium restriction controversy: challenging conventional practice. This includes precautions necessitating delay in vaccine administration, medical contraindication to vaccine, and resident refused or has already been immunized. Weakness and deconditioning will put you at risk for falls and fractures. SNF residents, however, tend to be older and have a higher comorbidity burden. Patients leaving the SNF should be discharged with a plan for ongoing HF management. The measures included in this 2011 HF performance measure set are shown in Table 10.237 These measures can be used internally within an organization to support quality improvement or publicly to compare the performance of providers, hospitals, outpatient care facilities, and healthcare organizations. The Minimum Data Set (MDS) is a general assessment performed on all patients on admission and at key intervals. use prohibited. End of life decisions in ICD patients with malignant tumors. Exercise based rehabilitation for heart failure. Frailty is usually described by reduced function in multiple domains, including nutrition or body weight, muscle strength, mobility, activity tolerance, and sometimes cognition.35–37 Although not synonymous with frailty, comorbidity (≥2 comorbid illnesses) is a pathogenetic risk factor for frailty.36 Although ≈20% of SNF residents have a diagnosis of HF, almost 70% of a Medicare sample with a diagnosis of HF had ≥3 noncardiac comorbidities, and 40% had ≥5.4,36–38 Frailty strongly correlates with HF.39,40 Frailty also confounds patient assessment and tolerance of medical therapies and increases mortality.41,42, General concepts of management of decompensated HF, or volume overload resulting in worsened HF symptoms in SNFs, are similar to those for management of outpatients. Associations of subclinical cardiovascular disease with frailty. [Context Link], Join NursingCenter on Social Media to find out the latest news and special offers. Frailty predicts long-term mortality in elderly subjects with chronic heart failure. Inspiratory muscle endurance in patients with chronic heart failure. Heart failure patients in skilled nursing facilities: evidence needed. Characteristics of patients who die with heart failure and a low ejection fraction in the new millennium. Clinical characteristics of nursing home residents hospitalized with heart failure. A 7-day follow-up appointment with the patient’s HF provider after SNF discharge is an important link back to the community. A caregiver should be identified and taught how to provide or assist with care for a person with HF who has been identified as having either a cognitive or sensory impairment. 1 Placement into class I, II, III, or IV of the New York Heart Association functional classification depends on the severity of patient symptoms and physical activity limitations. Echocardiography can evaluate left and right ventricular systolic function by two-dimensional imaging, and Doppler patterns can differentiate normal from restrictive from constrictive from impaired relaxation physiology. ORIGINAL ARTICLES… When a decision for deactivation has been made, the Heart Rhythm Society recommends a series of procedures that should be consistently applied. However, detecting changes in symptoms or function is complicated by factors such as cognitive impairment, sedentary lifestyles, and comorbid illnesses with overlapping symptom profiles.38,43 Cognitive impairment potentially affects capacity to report symptoms. Frailty and multiple comorbidities in the elderly patient with heart failure: implications for management. Absence of symptoms at rest does not necessarily indicate stable HF status.44. The clinical diagnosis of HF may largely rely on data from care before SNF admission. Several relevant HF outcome measures in current use include 30-day mortality and 30-day readmission rates after an acute care hospitalization.241,242 These measures at the hospital or system level incorporate risk-adjustment methodology to account for the often significant differences in patient populations across institutions.243 However, to date, there are no outcome measures specific to HF patients in SNFs. There are no data regarding the appropriate withdrawal of medications for patients with HF nearing the end of life; however, maintenance of volume status close to euvolemia and continuation of therapies that address the neurohormonal alterations of HF (such as ACEIs and β-blockers in HFrEF) palliate HF symptoms.212,220–222 All treatments ordered early in HF should be reevaluated in light of goals of care, particularly when patients or their surrogates have chosen to avoid hospitalization. SNFs should have a deactivation policy and processes in place that include magnet placement if needed (Class I; Level of Evidence C). Guidelines for nurse staffing levels are set by the Joint Commission on Accreditation of Healthcare Organizations Accreditation Code84; however, few SNFs are accredited by the Joint Commission on Accreditation of Healthcare Organizations. Vitamin D deficiency in patients with congestive heart failure: mechanisms, manifestations, and management. Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Improving heart failure disease management in skilled nursing facilities: lessons learned. To date, no pharmacological agents have been shown to improve survival, and thus, the goals of therapy for HFpEF are to alleviate symptoms, improve quality of life, and reduce hospitalizations. Teach her to avoid fats such as shortening, butter, and margarine and to eat only small amounts of olive and vegetable oil. When a patient is being transferred back to the hospital, the same information in Table 7 must be communicated to the hospital staff. Extubation process in bed-ridden elderly intensive care patients receiving inspiratory muscle training: a randomized clinical trial. It is important to maintain your activity level so you don’t become deconditioned. Subsequent post hoc analyses of the DIG trial data suggest that low-dose digoxin, as defined by a serum digoxin concentration <1.0 ng/mL, may be associated with improved survival in patients with HFrEF and NYHA functional class II to III symptoms.72 Although digoxin was equally safe in younger and older adults in DIG, there are few data on octogenarians and SNF residents. The usual long-term SNF resident is a white, non-Hispanic single female in her mid-80s10 with severe functional impairment,21 with 3 to 5 diagnoses, 1 of which is heart disease, and taking 9 medications.22. Evidence suggests that preparing low-sodium meals and allowing patients to add salt to taste at the table will result in lower total sodium intake while maintaining flavor. Heart Failure With Reduced EF. Staff education on HF monitoring and management should be provided regularly and tailored to all levels of healthcare providers (CNA, RN, nurse practitioner, medical doctor, physical therapist) (Class I; Level of Evidence C). In addition to the hospital staff providing adequate information (listed in Table 7), it is imperative that the hospital discharging team ensure that the patient can be managed adequately in the SNF. IMPROVE HF is a prospective study designed to evaluate the effectiveness of a practice-specific performance improvement intervention on the use of guideline-recommended therapies for patients with diagnosed HF and reduced LVEF or prior MI and reduced LVEF in outpatient cardiology practices. Sponsors (the American Heart Association [AHA] and the Heart Failure Society of America) identified specific members of the writing group, and others were selected on the basis of known expertise. Initial management of volume overload is appropriate in the SNF. Should implantable cardioverter-defibrillators and permanent pacemakers in patients with terminal illness be deactivated? A quality improvement project was completed in 4 northeastern SNFs.85Appendix 1 is an example of an HF-specific intake form. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Potential Causes of HF in Older Adults, Table 3. Educational interventions for patients with heart failure: a systematic review of randomized controlled trials. Heart Rhythm Society policy statement update: recommendations on the role of industry employed allied professionals (IEAPs). When will you see your healthcare provider? Position patient between supine to sitting to visualize the top of the venous pulsation. ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With HF Set: Dimensions of Care Measures Matrix. *Test measures designated for use in internal quality improvement programs only. This statement does not address care in other long-term care venues, such as assisted living or custodial care. For patients being discharged to home, options for self-management should be assessed simultaneously with arrangements for appropriate follow-up care (Class I; Level of Evidence C). Vitamin D biology in heart failure: molecular mechanisms and systematic review. Update on publicly reported outcomes measures based on the 2010 release. Content of HF Education for SNF Staff. Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Table 9 displays the content of HF education in relation to the level of the learner. In SNFs, nurse staffing is highly variable and includes predominantly unlicensed certified nursing assistants (CNAs) along with licensed RNs and licensed practical nurses (LPNs). Read HFSA Statements on COVID-19 here. 2015;8:655–687. After all educational programs, evaluation of learning ensures that knowledge and skill were transferred. β-Blockers improve survival in patients with HFrEF by reducing both sudden cardiac death and death attributable to pump failure.60–63 β-Blockers also improve survival for euvolemic patients with severe HF.64 β-Blockers reduce hospitalizations for HF exacerbations and may decrease the risk of supraventricular (and ventricular) tachyarrhythmias, including atrial fibrillation. Reduced peripheral skeletal muscle mass and abnormal reflex physiology in chronic heart failure. Many SNFs use therapy aides or assistants to deliver the therapy. MERIT-HF Study Group. Table 10. The most common reasons for rehospitalization among elderly Medicare beneficiaries with HF include not only worsened HF and electrolyte imbalances but also respiratory and urinary tract infections, sepsis, and altered mental status. Older people have an increased risk of ischemic heart disease, because aging is associated with endothelial dysfunction and progression of underlying coronary artery disease, as well as a decrease in capillary density and decreased coronary reserve, which can lead to insidious myocardial ischemia.14 In the Cardiovascular Health Study, the presence of coronary heart disease was associated with an 87% increased risk of HF despite the prevalence of hypertension being over twice as high as that of coronary heart disease. Furthermore, for a median duration of 7 days before overt HF decompensation, several signs and symptoms worsen.48–50 Monitoring for presence of increasing fatigue, dyspnea on exertion, cough, edema, and weight gain should signal nursing staff to intervene to avoid further decompensation. A link to the “Copyright Permissions Request Form” appears on the right side of the page. High-risk patients with HF have been shown to receive fewer life-prolonging therapies,246 and patients discharged to SNFs were less likely to receive guideline-recommended therapies in the absence of contraindication or intolerance.7 The simple dissemination of HF guidelines followed by written and verbal reminders about recommended actions has generally not been effective in improving the treatment of HF.233,247 Dissemination of guidelines must be accompanied by more intensive educational and behavioral interventions to maximize the chances of improving care.233 Chart audit and feedback of results, reminder systems to consider use of specific medicines or tests, use of clinical decision support, and the use of local opinion leaders have been shown to improve HF care in the inpatient and outpatient settings.233,248,249 Multifactorial interventions that simultaneously target different barriers to change tend to be more successful than isolated efforts.250,251 Efforts to monitor and improve the quality of HF care in SNFs will need to take into account the complexity of care, multiple comorbid conditions, social isolation, low health literacy, cognitive impairment, resource limitations, and patient preferences regarding goals of care.27,94,252, HF disease management programs and systems of care may improve care in the SNF setting7,26,27,94,252 and may reduce the frequency of hospitalization and improve quality of life and functional status in outpatients.7,250,251,253 Disease management for HF spans all settings in which the HF patient may be encountered and emphasizes care coordination and enhanced care transitions.233,251,253 Aspects of HF disease management programs that could be delivered in a SNF include intensive patient education, encouragement of self-care, and daily assessment of patient status. 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