Heart Failure From Admission to Discharge

1
Heart FailureFrom Admission to Discharge

• June 7, 2005
• Speakers
• Joseph Sopko, MD
• Consultant, Ohio KePRO
• Amanda Caldwell, RN, BSN, MBA
• St. Charles Hospital - Oregon, OH

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Objectives

• List the four (4) Heart Failure measure
  specifications.
• Discuss diagnostic studies for differential
  diagnosis.
• Describe one implementation process relating to
  the six (6) written patient discharge instruction
  elements that must be documented in the medical
  record.
• Explain the process for medical record
  abstraction for the six (6) discharge instruction
  elements and their impact on validation.

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Heart Failure Measure Specifications
Documentation in the medical record that left
ventricular function (LVF) was assessed before
arrival, during hospitalization or is planned
after discharge.
LVF ASSESSMENT
Ventricular systolic dysfunction (LVSD) and
without ACEI contraindications are prescribed an
ACEI at discharge. Heart failure patients with
left.
LVSD ACEI
Heart failure patients with a history of smoking
within the past 12 months are given smoking
cessation advice or counseling during the
hospital stay.
SMOKING CESSATION
Heart failure patients are discharged with the
following written instructions activity level,
diet, discharge medications, follow-up
appointment, weight monitoring, and worsening
symptoms.
DISCHARGE INSTRUCTIONS
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Heart Failure Differential Diagnosis

• Definition Heart Failure is a complex clinical
  syndrome that can result from any structural or
  functional cardiac disorder that impairs the
  ability of the ventricles to fill with or eject
  blood.

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Heart Failure Differential Diagnosis

• Stages of Heart Failure (HF)
• Stage A Identifies the patient who is at high
  risk for developing HF but has no structural
  disorder of the heart.
• Stage B Refers to a patient with a structural
  disorder of the heart but who has never developed
  symptoms of HF.
• Stage C Denotes the patient with past or
  current symptoms of HF associated with underlying
  structural heart disease.
• Stage D Designates the patient with end-stage
  disease who requires specialized treatment
  strategies such as mechanical circulatory
  support, inotropic infusions, transplantation, or
  hospice care.

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Heart Failure Differential Diagnosis

• Patient Assessment
• Complete history and physical
• Left Ventricular Function Assessment
• Echocardiogram
• Nuclear medicine test
• Cardiac catheterization with left ventriculogram
• Chest radiography
• Brain natriuretic peptide (BNP)
• Laboratory testing
• Blood count
• Urinalysis
• Serum electrolytes
• Blood lipids
• Renal and hepatic function
• Thyroid function test

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Patient Education Principles
The patient receives education and training
specific to the patients assessed needs. The
assessment is completed at the time of the
admission assessment.
Assessment
The patients readiness to learn is based on the
patient not on the staff.
Readiness
Involve the patients family and /or care-giver
as appropriate.
Instructee
The teaching methods are contingent on the
patients abilities, learning preference,
language, and knowledge of the disease and
treatment orders and modalities.
Method
The effectiveness of the patients education is
monitored and interactive. It is important to
elicit feedback to ensure that the information is
understood, appropriate, and useful.
Response
If the patient and/or care giver does not
comprehend the teaching the staff may provide
additional instruction or reinforcement of
previous instruction.
Remedial
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Heart Failure Written Discharge Instructions

• Six written discharge instruction elements
• Activity Level
• Diet
• Medications
• Follow-Up appointment
• Daily weight monitoring
• Worsening Symptoms

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Written Activity Discharge Instructions

• Tips for Activity
• Comfortable shoes and clothing
• Do not exercise on a full or empty stomach
• Exercise in comfortable temperature, between 40
  and 80 degrees Fahrenheit
• Always warm up, cool down with stretching and
  slow walking
• Do not hold your breath during exercising or
  other physical activity
• Exercise when you feel most energetic
• Make sure you can carry on a conversation while
  you are doing any activity

• When to slow down
• When you have shortness of breath or more
  symptoms than usual
• Feel exhausted
• Have a fever, infection, or feel ill
• Have chest pain
• Are going through a major change in medications
• Have signs of overexertion
• Shortness of breath
• Dizziness or lightheadedness
• Pain chest, arms, shoulders, neck or jaw
• Irregular heart beat/pulse
• Unusual/extreme fatigue
• Sweating, nausea, or vomiting

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Written Diet Discharge Instructions

• How to follow a low sodium diet
• Stop adding salt to your food
• Adapt preferred foods to low-sodium versions
• Select foods low in sodium
• Read food labels
• Take the salt shaker off the table
• Use low or no salt herbs and spices
• Get a low-sodium cookbook
• Minimize use of condiments
• Avoid dishes named au gratin
• Get a food list that describes sodium content

• Additional considerations
• Define low sodium diet, amount of sodium intake
  per day
• Discuss other special diets, low fat, diabetic,
  and limited calorie
• Potassium considerations
• ACE may increase potassium level
• Water pills may decrease potassium level
• Medications that might have sodium in them
• Some antibiotics
• Medications that fizz

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Written Worsening Symptoms Discharge
Instructions

• Call your doctor or nurse if you
• have any of the following
• symptoms
• Weight gain or or loss of 2 or more pounds in one
  day, or 4 pounds in one week
• Swelling in the legs, feet, hands,abdomen
• Increasing fatigue
• Loss of appetite or nausea
• Feeling of bloating or fullness in your stomach
• Confusion or restlessness
• Intermittent or mild shortness of breath
• Dizziness or lightheadedness
• Persistent cough chest congestion

• Additional considerations
• Emergency Symptoms of Heart Failure call 911 if
• Chest pain/discomfort lasting more than 15
  minutes and not relieved with rest or
  nitroglycerin
• Severe persistent shortness of breath
• Fainted or passed out
• Urgent Symptoms of Heat Failure
• New or increasing shortness of breath at rest
• Difficulty sleeping due to shortness of breath
• Need to sit up or use more pillows than usual
• Fast or irregular heart beat/pulse, dizzy or
  lightheaded, feeling faint
• Cough up frothy or pink sputum

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Written Daily Weight Discharge Instructions

• Monitoring your weight and
• swelling on a daily basis
• Swelling sometimes called edema
• Increase in weight may be a sign that fluid id
  building up in your body your shoes, rings, and
  clothes may feel tight
• Extra fluid causes swelling in your legs and
  ankles
• You can gain weigh without swelling. The average
  person can hold about 8-15 extra pounds of fluid
  before swelling develops
• Check your weight every day to catch weight gain
  before swelling takes place
• The goal is to identify weight gain early and
  take steps to remove extra pounds
• Cut the sodium
• Decrease amount of fluid you drink
• Notify your physician

• Additional considerations
• Document your weight on the morning of the day
  after you get home from the hospital.
• This weight is called your dry weight. Your
  dry weight is related to the amount of fluid
  retained in your body due to heart failure.
• Weigh yourself at the same time, on the same
  scales, in the same clothes. Weigh yourself after
  you urinate, and before breakfast and/or have a
  bowel movement
• If you change your routine your weight could vary
  by 2 or more pounds
• Document your weight every day
• Compare your daily weight to your dry weight
  not yesterdays weight
• Take your weight chart with you when you visit
  the doctor

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Written Follow-Up Discharge Instructions

• Follow Your Treatment Plan
• Take medications as directed
• Weight yourself every day
• Control your weight
• Follow your low sodium diet
• Get your immunization shots
• Get regular physical activity
• If you use tobacco Quit
• Avoid alcohol or drink sparingly

Visit your physician or nurse on a regular basis
as scheduled
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Written Medications Discharge Instructions

• Other medications
• Hydralazine and Isosorbide Dinitrate
• Anticoagulate Medications
• Potassium Pill
• Medications to avoid
• NSAIDs
• Calcium channel blockers
• Most antiarrhythmic medications
• Tell your patients
• What the medication will do for you
• Why it is important to take the medication
• Establish a medication routine
• Common side effects
• Consult your physician/nurse before taking
  alternative therapies
• Be sure to address all discharge medications the
  patient will use after discharge
• Call your physician/nurse if your side effects
  worsening

• Medications help stabilize heart function they
  will help you
• Live longer
• Have fewer symptoms
• Breathe more easily
• Have more energy
• Increase activity level
• Have less swelling
• Stay out of the hospital
• Heart failure medications
• Angiotensin-converting enzyme inhibitors (ACEI)
• Beta-Blockers
• Digoxin
• Diuretics
• Aldosterone antagonist
• Angiotensin receptor blockers (ARBS)

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CDAC Validation

• The CDAC must find proof of WRITTEN discharge
  instructions addressing the following areas
• Discharge Instructions
• Diet
• Activity Level
• Follow-Up Instructions
• Weight Monitoring
• Symptoms Worsening

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Abstracting Medications

• Abstraction requires a two-step process
• Review all discharge medications documentation
  available in chart (physician orders, discharge
  summary, progress notes) and determine all
  medications being prescribed at discharge.
  Compile a discharge medication list to compare
  against the discharge instructions sheet.
• Check this list against the written discharge
  instructions given to the patient. The
  instructions need to address at least the names
  of all the discharge medications.

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Common Medication Abstraction Issues

• Discharge instruction sheet noting to continue
  home meds or resume meds is not sufficient and
  should be abstracted as No.
• If discharge medications are noted using only
  references such as continue present meds or
  continue current meds rather than a list,
  compile the list by referencing the MAR. Exclude
  medications to be discontinued at discharge.

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Common Medication Abstraction Issues

• Orders such as resume home meds and no list of
  discharge medications is evident in the record
  then compare the patients pre-arrival medication
  to those on the discharge sheet. To confirm
  completeness compare all available sources
  including HP, ED intake form, and Nursing
  admission assessment.

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Common Medication Abstraction Issues

• When there is conflicting information between a
  specific list and a general reference, consider
  the list most accurate.
• Example
• If medication listed in the discharge summary
  match the medications listed on the discharge
  instruction sheet, but the physician also stated
  continue home meds on his orders and some of
  the home meds are not addressed answer yes.

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Common Medication Abstraction Issues

• If the only documentation of discharge
  medications is found on the discharge
  instructions answer No since the completeness
  of the list cannot be confirmed.
• Medications documented in the discharge summary
  such as hold ASA until Monday should be
  included on the discharge instruction form. If
  not, the abstractor should answer NO.

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Other Discharge Instruction Issues

• Videos that cover discharge instruction elements
  do not meet the instruction measure.
  Instructions must be WRITTEN.
• Discharge instruction statements such as Call
  your doctor if you have more than 3-5 lb weight
  gain within one week count as both Weight
  Monitoring and Symptoms Worsening.
• Hospitals that rely on brochures for discharge
  instructions elements should include a copy of
  the brochure in each HF record submitted to the
  CDAC for validation.

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Other Discharge Instruction Issues

• If the discharge instructions elements addressed
  by the brochure have been explicitly documented
  in the record, a copy of the brochure is not
  required.
• Example
• Patient received the CHF Handbook which
  provides patient information on diet, exercise,
  weight monitoring, and what to do if symptoms
  worsen is adequate documentation for these
  discharge instruction elements.

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Publication No. 4020-OH-061-05/2005. This
material was prepared by Ohio KePRO, the Medicare
Quality Improvement Organization for Ohio, under
contract with the Centers for Medicare Medicaid
Services (CMS), an agency of the U. S. Department
of Health and Human Services.The contents
presented do not necessarily reflect CMS policy.