Outpatient Management of Heart Failure

More documents

Recommendations

Info

Introduction ♥4 Heart failure (HF), the heart’s inability to pump an adequate volume of blood to the tissues, is the only major cardiovascular condition that continues to increase in incidence in the United States today. 1 For most physicians, the concept of HF conjures up an image of the decompensated, critically ill patient, and most often one who is hospitalized. This reflects the fact that in the majority of cases modern medicine is brought to bear in HF treatment in the hospital environment and typically in the most congested settings with overcrowded conditions—emergency departments (ED), and intensive care and telemetry units. Nearly 5 million patients are currently diagnosed with HF in the United States today. The American Heart Association estimates that between 400,000 and 700,000 new HF cases develop each year. 2 This condition is responsible for an estimated 900,000 hospitalizations annually—more than any other medical condition among the elderly. 3 Approximately 6.5 million hospital days each year are attributed to and related to HF and as many as one third of those patients are readmitted for treatment of symptom recurrence within 90 days. Thus, it is not surprising that the cost of providing advanced medical care for the millions of patients suffering from HF is extraordinarily high—now estimated at more than $38 billion annually. 4 The problem is further complicated by inadequate reimbursement to the treating hospitals, which places an inordinate economic burden on the overall healthcare system. From this has sprouted an increasing awareness among healthcare professionals that delivering appropriate care for patients with HF in the outpatient setting (thus reducing hospitalizations and the associated costs) is of distinct clinical benefit to most patients with HF as well as financially stressed hospitals. After many years of dedicated effort in caring for patients with HF and their families, the authors share the belief of many other field professionals that in most cases HF should be considered an outpatient condition, and experience has shown that with the absence of EDs, critical care units, and hospital beds, the outpatient arena provides an optimal setting for appropriate diagnosis, treatment, clinical improvement, and ultimately perhaps even the prevention of HF. The authors have dedicated 2 decades to the development and implementation of a number of HF centers, thus combining prior clinical experience with HF evidence-based medicine to advance the concept of outpatient treatment. We have been fortunate to work within a healthcare system of more than 9 area institutions that share the commitment (and foresight) to make excellence in HF care a system-wide priority. Moreover, the entire system has achieved Disease Specific Certification in Heart Failure by the Joint Commission on Accreditation of Healthcare Organizations, reflecting this center’s emphasis on coordination of care and support of patient self-management, effective use of evidence-based guidelines to manage care, and measurement and improvement of health outcomes. These accomplishments (the result of the hard work and dedication of many healthcare professionals who maintain a daily focus on the mission, values, and philosophy of the Advocate Health Care System) can be readily replicated in other US medical centers. This publication is designed to provide an overview of the Advocate Heart Failure Institute and the Heart Failure Center, as well as supporting patient care and research arms. The overall objective of this effort is to focus on the structure and treatment approaches employed in this center and share with a wider profes- sional audience the lessons learned in the development and implementation of a comprehensive outpatient HF management program. It is hoped that this Institute’s experience will further encourage the establishment of such centers at other institutions that are similarly dedicated to optimal disease management outside the hospital environment for the benefit of the many millions of patients with HF. Overview of Outpatient Heart Failure Disease Management Results of the first randomized clinical trial of a HF disease management program by Rich and colleagues 5 demonstrated that patients participating in an outpatient clinic program who subsequently required readmission to the hospital for HF were less acutely ill and required a shorter period of hospitalization. This study and others have shown that availability of a HF outpatient management program leads to reductions in 30% to 44% in all-cause admissions and more than a 50% decrease in the rate of admissions for HF. 6–8 Some common features of successful disease management programs include disease specificity, promotion of patient self-management, and patient-specific treatment and intervention plans. The common features of such disease management programs include disease specificity, promotion of patient self-management, standardized delivery of care method in accordance with clinical guidelines and/or evidence-based practice, patient-specific treatment and intervention plans, comprehensive care along the continuum of the disease and healthcare delivery systems, and measurement and analysis of clinical outcomes to improve treatment plans. In addition to the obvious benefit of reducing the number of patients who may require hospital readmission for HF within 30 days of discharge, experience has shown the significant cost/benefit potential in establishing an outpatient HF management program. Recognizing the chronic shortages of inpatient bed availability in most hospitals today, any reduction in the hospitalization rate for HF is clearly advantageous for each individual institution as well as for the healthcare system as a whole. The Experience at Advocate Health Care In 1995, the first system-wide continuous quality improvement project to optimize the health of patients with HF and reduce rehospitalizations was established by Advocate Health Care. This continuum of care program was developed by a 20-member implementation team and physician advisory group comprised of cardiologists, clinical nurse specialists, pharmacists, and quality management personnel. The principal objectives of this comprehensive outpatient HF management program were to (1) ensure close collaboration between physicians and the multidisciplinary HF team, (2) provide an intermediary care site between physician offices and the acute care institution, and (3) enhance quality of care and patient satisfaction. The overall program was designed to shift patient management from the “crisis intervention” mode to a more comprehensive care
approach delivered in hospital, home, and outpatient settings. Core components of this effort included patient evaluation, delivery of comprehensive care, close individualized patient monitoring, ready access to clinic staff to permit immediate response to any patient crisis, intensive patient and family education and reinforcement, and compliance tracking to ensure patient adherence to the prescribed multidimensional treatment regimen. As stated in the Heart Failure Institute’s formal mission statement, this integrated, systematic approach to patient care incorporates proactive interventions, measurements, and refinements designed to provide patients with HF with the self-care skills and educational support necessary for understanding and effectively managing their condition. In addition to understanding the disease process itself, participants assume an active role in their own clinical management by maintaining a proper diet, monitoring their fluid intake, and tracking their weight on a daily basis. During the 7 years since inception of this outpatient HF management program, the scope of its services, staffing needs, treatment approaches, and goals has continued to evolve as the result of ongoing clinical experience. Typically, an HF clinic nurse first identifies the patient during hospitalization and then schedules an initial visit to explain the program, its objectives, and potential long-term management benefits. This is followed by initiation of the patient education process, working with the inpatient staff to prepare the patient for discharge, and subsequently following up to ensure establishment of an appropriate outpatient and/or homecare program. Following initial assessment, the HF nurse and cardiologist develop an appropriate plan for implementation of both medical and nonpharmacologic treatments, based on current American College of Cardiology/American Heart Association (ACC/AHA) guidelines (http://www.acc.org/clinical/guidelines/failure/pdfs/hf_fulltext.pdf). Rather than classifying patients with HF according to the degree of exertion required to produce symptoms (as per the New York Heart Association [NYHA] functional classifications I-IV), the ACC/AHA classification assesses HF as a continuum, beginning with patients at risk for HF (stage A) and then progressing to those with asymptomatic left ventricular dysfunction (stage B), those with symptomatic HF (stage C), and patients suffering from advanced irreversible HF (stage D). The relationships between the various ACC/AHA stages and NYHA functional classes are shown in Table 1. As with any evaluation of this type, it is important to identify reversible causes of HF so that appropriate surgical interventions can be optimized (eg, revascularization, valve replacement, cardiac resynchronization therapy, left ventricular assist device placement, or heart transplant evaluation). Patients also are evaluated as potential participants in ongoing clinical research trials of newer pharmacotherapeutic, device, and surgical approaches to HF treatment. ♥ 5 TABLE 1 9 Classification of HF: Relationship Between ACC/AHA HF Stage and NYHA Functional Class ACC/AHA HF Stage 10 NYHA Functional Class 11 A At high risk for HF but without structural heart disease or symptoms of heart failure (eg, patients with hypertension or coronary artery disease) B Structural heart disease but without symptoms I Asymptomatic of HF C Structural heart disease with prior or current II Symptomatic with symptoms of HF moderate exertion III Symptomatic with minimal exertion D Refractory HF requiring specialized interventions IV Symptomatic at rest ACC/AHA = American College of Cardiology/American Heart Association; NYHA = New York Heart Association. The 1994 Cardiology Preeminence Roundtable assessed the results of HF patient management and strongly recommended the clinic approach. 12 It gave its highest rating to structured outpatient programs as most likely to generate significant reductions in total cost of care. The Advocate Heart Failure Center’s outpatient management program facilitated an overall reduction in the 30-day readmission rate for HF from 10% in 2000 to 7% in 2001.
Page 1 and 2: Second Edition Outpatient Managemen
Page 3 and 4: Target Audience This activity has b
Page 5: TABLE OF CONTENTS Introduction.....
Page 9 and 10: FIGURE 1 13 Evaluation and Treatmen
Page 11 and 12: Transitioning Management From Inpat
Page 13 and 14: Drug Treatment Protocols in Heart F
Page 15 and 16: Is SBP < 90 mmHg and/or SVR < 800 d
Page 17 and 18: TABLE 13 21 Mortality (High-Risk St
Page 19 and 20: CASE 2 Background A man aged 46 yea
Page 21 and 22: CASE 4 Background This woman aged 6
Page 23 and 24: Other Issues, Considerations, and I
Page 25 and 26: Congestive Heart Failure Orders (Ad
Page 27 and 28: DIET/FLUIDS A balanced diet is impo
Page 29 and 30: Dear Doctor: After having seen your
Page 31 and 32: Outpatient Management of Heart Fail
Page 33 and 34: Follow-up As part of our ongoing co
Page 35 and 36: ♥ 33

Outpatient Management of Heart Failure

Create successful ePaper yourself

Delete template?

Save as template?