Sir Muir Gray, Director,

Transcription

1 Incorporating Specialty Nurses and Advanced Nurse Practice into Multidisciplinary i li Heart Failure Team Abdiqani Qasim, MScN, FNP, ACNP Head, General Nursing Training, Unit

2 Knowledge is the enemy of disease The application of what we know will have a bigger impact on health and disease than any single drug or technology likely to be introduced in the next decade. Sir Muir Gray, Director, NHS National Knowledge Service

3 Simple hand washing to prevent transmission of disease Elevation HOB to prevent VAP

4 CHF Population Salt & Fluid restriction Daily weight Activity i monitoring i demand d & Supply Medication Sign and symptoms to watch Important of follow up appointments When to call help

5

6 Advanced dn Nursing Practice Advanced Nursing Practice (ANP) is an umbrella term. It describes an advanced d level l of nursing practice that t maximizes the use of in-depth nursing knowledge & skill in meeting the health needs of clients. In this way, ANP extends the boundaries of nursing's scope of practice & contributes to nursing knowledge & the development & advancement of the profession (CNA 1999)

7 Acute Care Nurse Practitioner ACNP The Acute Care Nurse Practitioner is an academic title used to describe an RN who has completed education at a graduate level, in an ACNP program, with a focus on a sub-specialty specialty (NPAO 2002)

8 Advanced Practice Nurse APN An ACNP is an advanced practice nurse who works collaboratively with members of the health care team, not only to provide individual patient care, but also to improve practice, using evidence based research to develop, implement & evaluate care Canadian Association of Advanced Practice Nurses (CAAPN) 2003

9 Background Heart failure (HF) is a syndrome of shortness of breath and fatigue. It occurs when forward flow of blood out of the heart is impeded. This is the only cardiovascular condition that continues to increase in prevalence and incidence. It is a major healthcare problem, not only for the patient, but also for significant others and the community at large.

10 Background HF is a leading cause of hospitalization and death world wide, and its prevalence continues to increase. The clinical care of patients with HF encompasses a continuum from the treatment of acute episodes requiring ii hospitalization to chronic management in the outpatient office setting.

11 Heart Failure Impact

12 Barriers sto Effective ectve Heart Failure Management age e Rich et al, Journal of Cardiac Failure Vol. 5 No. 1 March 1999

13 Evidences

14 Heart Failure Future 14

15 Lothian Managed Clinical Network (Heart Failure) Rehabilitation General practitioner Specialist HF nurses District nurse Patient Cardiologist Specialist/EP Volunteer support workers Geriatrician/care of the elderly elderly Social Services Pharmacist Palliative Care team Dietitian

16 Cycles of Heart Failure Care Home Hospitalisation GP Clinic OP clinic

17 Role of APN Incorporating specialty nurses and NPs into multidisciplinary heart failure teams enhances the efforts of cardiologists and improves patient access to medical care and education. Nurses working within such a framework develop significant expertise in the narrowly focused area of heart failure management to implement, coordinate, and monitor all aspects of heart failure care.

18 Role of APN They are able to: Monitor hemodynamic status, Titrate medications, Review results of laboratory testing, and Triage calls from patients, which may prevent repeat hospital admissions. Nurses may transplantation, support. also assist end-of-life with care, end-stage strategies of or mechanical circulatory

19 Case Study The following case studies demonstrate the role NPs play in acute and chronic heart failure care Mrs. KN is a 68-year-old woman admitted with progressive dyspnea, abdominal bloating, and cough. When severe orthopnea developed, she presented to the emergency room.

20 Case Study History of Present Illness Bt Beta blockers for lft left ventricular ti dysfunction, discontinued d several months prior to admission, were restarted 1 week prior to admission after a nuclear study suggested a decrease in left ventricular ejection fraction (LVEF).

21 Case Study Past Medical History 1999: non-hodgkin's lymphoma treated with adriamycin 2000: tricuspid valve repair 2000: cardiomyopathy (presumed adriamycin-induced), induced), initial LVEF 20% 2001: LVEF improved to 50% with medical therapy 2005: implantable cardioverter-defibrillator defibrillator for nonsustained ventricular tachycardia

22 Case Study Admission Medications Mrs. KN currently takes: Furosemide Potassium Simvastatin Lisinopril, and Carvedilol.

23 Case Study Plan of Care/Clinical Course Mrs. KN was admitted d to an acute care floor rb by the general cardiology service with a presumed heart failure exacerbation. The attending cardiologist i requested a formal consultation by the heart failure service. The acute care nurse practitioner (ACNP) proceeded with a thorough history and physical exam: Vital signs: blood pressure (BP) 102/70 mm Hg, heart rate 92 bpm, SaO2 96% General demeanour: no distress; pleasant and cooperative Chest: clear lungs

24 Case Study Cardiovascular: heart rhythm regular, II/VI holosystolic murmur, laterally displaced point of maximal impulse,, jugular jg venous distension (~ right atrial pressure about 14 cm H20) Abdomen: soft, active bowel sounds, right upper quadrant tenderness, liver edge at the costal margin, overall liver height 8 cm Extremities: no edema, slightly cool Admission laboratory results and diagnostic tests: B-type natriuretic peptide 1287 pg/ml, all other labs normal; Electrocardiogram: normal sinus rhythm

25 Case Study The ACNP discussed Mrs. KN's case with the attending physician, and it was mutually agreed that the patient needed intravenous (IV) diuretics and monitoring of diuretic response. The beta blocker was discontinued, given her volume- overloaded dd state. Mrs. KN was given furosemide 40 mg IV. Over the next 2 hours, the symptoms improved as she started to diurese. However, she had a reported decrease in BP to 85/60 mm Hg. Sheremained asymptomaticand ti and alert.

26 Case Study The BP was confirmed with a manual sphygmomanometer in both arms. The ACNP discontinued her lisinopril and discussed plans with the attending physician for transfer to the intensive care unit and invasive hemodynamic monitoring i should Mrs. KN's BP continue to decline. Over the next hour, KN's BPfellto78/56 mm Hg. Echocardiogram was ordered: LVEF was again 20% with moderately severe mitral regurgitation and evidence of pulmonary hypertension.

27 Case Study The ACNP discussed Mrs. KN's hypotension and ventricular function with the attending physician, patient, and the family. KN underwent pulmonary artery catheter placement. Her hemodynamic status showed: Mean right atrial pressure: 25 mm Hg Mean pulmonary capillary wedge pressure: 31 mm Hg Pulmonary artery pressures: 38/56 mm Hg Cardiac output: 2.8 L/min; cardiac index: 1.4 L/min/m2 Mixed venous saturation: 40%

28 Case Study Mrs. KN was transferred to the coronary care unit with an indwelling pulmonary artery catheter. Milrinone 0.3 mcg/kg/min and a continuous furosemide drip were started. Care was managed by an intensive care unit fellow and the attending physician. The ACNP resumed care after KN had stabilized and transferred from the intensive care unit to the acute care floor.

29 Case Study She had lost 5kg of body weight. Orthopnea symptoms had completely resolved and BP had stabilized. KN was slowly weaned off milrinone and transitioned to an oral diuretic regimen, and lisinopril i was restarted rt The ACNP provided discharge planning, which consisted of patient and family education about heart failure self-management, including follow-up appointments, what to monitor at home, and when to call if changes in symptoms occur.

30 Case Study The ACNP provided discharge documentation mandated by the Joint Commission for Accreditation of Hospital and the Centers for Mdi Medicare Services Assessment of LV function; Recommendation for treatment with angiotensin converting enzyme (ACE) inhibitors in the event that LVEF drops below 40%; and Discharge instructions on medications, Weighing g daily at home, Maintaining activity, Restricting sodium, and when to call about worsening symptoms. Plans for resuming the beta blocker would occur in the outpatient setting

31 Case Study Summary This is an example of how an ACNP functions as part of a team to provide consultative services to ageneral cardiologist for someone hospitalized with heart failure. The ACNP was able to adequately assess volume and perfusion status of a patient with acutely decompensated heart failure, and then make a collaborative plan with the attending physician.

32 Case Study Understanding hemodynamic compromise, using evidence-based medicines, monitoring response to therapy, and adjusting the plan of care for deterioration in clinical status are all within the scope of an ACNP. In this case, the ACNP was able to collaborate with others to intensify care when needed, then to resume care and prepare the patient and family for discharge.

33 Case Study 2: Mr. P's Cardiomyopathy y and Heart Failure Mr. P, a 28-year-old male, was hospitalized with new- onset heart failure, which was diagnosed as idiopathic dilated cardiomyopathy. The left ventricular ejection fraction was 18%. The heart failure and transplant team started a comprehensive workup for cardiac transplantation in case Mr. P failed medical therapy.

34 Case Study 2: Mr. P's condition stabilized. He was given diuretics and started on an angiotensin converting enzyme inhibitor and discharged home. The outpatient plan was for close follow-up and titration of prognosis-altering medications as tolerated.

35 Case Study 2: The heart failure nurse practitioner (HF NP) saw Mr. P for his first outpatient visit. Hospital records gave a clear history and plan for outpatient management

36 HF NP Assessment (Post Discharge) Mr. P had done well since his hospitalization. He kept records of his vital signs: His systolic blood pressure (BP) ranged from mm Hg, Heart rate was in the 80s, and His weight only fluctuated 2 lbs in the last 5 days.

37 HF NP Assessment (Post Discharge) He was clearly less short of breath than before his admission, and no longer noted orthopnea. He had no chest pain, light-headedness headedness, or syncope. He was eating and sleeping well, and was tolerating slow walks with his wife and new baby. He was trying to adhere to a low-salt, fluid-restricted diet, but it was "tough."

38 Discharge Medications Mr. P was currently taking: Lisinopril 5 mg daily, Furosemide 40 mg twice a day, Digoxin 0.25 mg daily, potassium 20 meq twice a day, and a multivitamin daily. Physical Examination Vital signs: BP 106/64 mm Hg, Heart rate 83 bpm, Weight 84 kg, SaO2 95% General: No distress Chest: clear lungs

39 Discharge Medications Cardiovascular: regular rate and rhythm; no extrasystoles; II/VI systolic murmur left of sternum and radiating to axilla; neck veins not distended; no edema; peripheral pulses intact Abdomen: normal exam Extremities: normal pulses

40 Assessment Mr. P had an idiopathic dilated cardiomyopathy with new-onset heart failure symptoms. He was diagnosed and stabilized in the hospital setting. He was currently in Stage C and had New York Heart Association Class II symptoms. He was tolerating his new medications without problem, was euvolemic (ie, not retaining fluid), and had a stable blood pressure in clinic and at home.

41 Plan of Care/Clinical Course A regimen of Carvedilol mg twice daily was prescribed. Mr. P was given samples, and the medication name and dose were added to his written list from the hospital.

42 Plan of Care/Clinical Course He was instructed to continue self-monitoring and to call the HF NP if he had worsening dyspnea, weight gain, or other symptoms. He was also instructed that, although beta blockers provide morbidity and mortality benefits, they would take time to work.

43 Plan of Care/Clinical Course Mr. P was instructed that he will need close follow-up for titrations every 2 weeks, as tolerated. He was commended d on keeping records rd and bringing them to the clinic appointment. Suggestions on how to flavour food while avoiding salt were provided. The HF NP completed the appointment by answering any remaining questions.

44 Plan of Care/Clinical Course The long-term plan of medical therapy was reiterated. Transplantation would be considered if his condition deteriorated. The risk of sudden death had been discussed in the hospital, and it was agreed to wait until medications had been appropriately titrated before assessing the need for a prophylactic p internal cardiac defibrillator.

45 Summary This case demonstrates how an outpatient HF NP provided care to a patient recently discharged with acutely decompensated heart failure. An outpatient HF NP's role includes: Knowledge about the hospital course, Assessing toleration to medications, Evaluating volume and perfusion status, Offering further patient self-management education, and Initiating prognosis-altering medications.

46 Summary Other considerations of outpatient management include managing co morbidities of heart failure and assessing the need for other therapies based on the stage of heart failure

47 Conclusion Newer models of care are needed to accommodate the needs of the growing population of heart failure patients and the wide range of treatments available. Recent discussions centered on narrowing the gap between the need for and supply of heart failure specialists fail to fully acknowledge the role specialized nurses now have in improving the delivery of heart failure care. Nurses can function as "heart failure specialists," complementing and augmenting the vital role of heart failure cardiologists.

48 Conclusion When studied in the context of multidisciplinary teams, often led by cardiologists, nurse specialists have been shown to contribute significantly to improving outcomes. While the need for a fully recognized ed heart failure subspecialty within cardiology is clear, national organizations are now planning for a cardiovascular specialty within nursing. Future crises in heart failure management may be mitigated in part by more uniformly adopting nurse specialists to perform many of the core cognitive functions of integrated disease management.

49 Conclusion Concerns are mounting regarding g the limited availability of heart failure specialists. Specialized providers are in greater demand db because of a growing number of cases of heart failure and the advancement of technology that has made complicated treatment strategies possible. While many solutions are being explored to bridge the gap between the number of qualified specialists and projected needs, the role nurses play has received limited analysis.

50 Conclusion Strategies using the expertise provided by specialized nurses have generally shown improved heart failure outcomes. Nurse specialists should not be overlooked as part of the solution for providing care to those afflicted with heart failure.

51 Pathogenesis Primary damage myocyte loss overload Necrosis apoptosis Stretch Pump dysfunction Neurohumoral activation Ventricular remodeling SNS RAAS, AVP Edema, tachycardia vasoconstriction, congestion CHF