2012 CCU Competency

1. 2012 CCU Competency HF Module 2: Nursing Driven Care and Quality Outcomes

2. Goals for this module • Assessment of dyspnea • Volume status • Self care management: • Focus on diet and medications • Transitions of care

3. Assessment of Dyspnea • Congestion is the most common reason for HF admissions. • Dyspnea is the most common symptom associated congestion. • Improvement in dyspnea is a primary goal of treatment. • When assessing for dyspnea it is important to include the following in your assessment: • Is your assessment at rest or with exertion? • If the assessment is with exertion – how much exertion? • This is why it is important for HF patients to participate in Phase I Cardiac Rehab to allow for a systematic way to assess activity tolerance. • Each step in Phase I Cardiac Rehab is associated with a metabolic equivalent of activity which can be translated to activities of daily living. • It is also important to know if the patient becomes dyspneic with minimal exertion such as talking or changing positions in the bed. • If dyspnea is at rest, it is important to know if the patient is dyspneic in the full upright position or when lying flat (orthopnea).

4. Volume Status • Many patients who are congested are volume overloaded. • However, it is possible to have pulmonary congestion without significant volume overload. This often occurs in HF patients who are hypertensive. An increase in hydrostatic pressure can push fluid out of the vascular space and place the patient at risk for flash pulmonary edema. • Daily weight and I&O are two important tools used to assess volume status. • The process for accurate I&O is already well defined through CCU Shared Decision Making and is an expectation for everyone. • The results of the daily weight should match the results of the 24 hour I&O. For example: A negative fluid balance on I&O should correspond to a decrease in the daily weight.

5. Volume status • Daily weights need to be completed on every patient admitted with HF as well as anyone with a history of HF (Remember: We have instructed these patients to weigh daily at home). • Always indicate the type of scale used for obtaining a daily weight. • If the patient is able to stand, a standing scale should always be used. This reinforces the patient’s involvement in care. • If a bed scale is used, the weight should be done with a bottom sheet, one pillow, a pull pad, a top sheet, and one blanket only according to hospital guidelines. Please remember to calibrate the bed before admitting the patient in the bed. • When a patient is able to be transferred from bed weight to scale weight, both weights need to be recorded on the day of transition. There will always be some variation between the two methods and thus both weights need to recorded at the time of transition to allow for comparison between weights recorded in the same way.

6. Day 1 Bed Scale 79.9 kg Day 2 Bed Scale 78.3 kg (down 1.6 kg) Day 3 Bed Scale 76.9 kg (down 1.4 kg when comparing bed scale to bed scale) Day 3 Standing Scale 75.9 kg (*down 2.4 kg when comparing bed scale to standing scale) Day 4 Standing Scale 76.3 (up 0.4 kg when comparing standing scale to standing scale) (*down 0.6 kg when comparing standing scale to bed scale) Example: * Note the inaccurate conclusions that are drawn when comparing two different scales, including the difference between a weight loss and a weight gain.

7. Sodium Restriction and volume status Except for unusual circumstances – the patient with HF should be on a sodium restricted diet of 2 grams of sodium per day. Please advocate for your patients by assuring a 2 gram sodium diet is ordered. Water follows sodium and the failure to restrict sodium can interfere with the ability to effectively diurese. HF patients who are hyponatremic are usually hyponatremic because they have an excess of free water in relationship to normal sodium. The treatment is to restrict fluid rather than add salt. These patients should also be a sodium restricted diet because liberalizing sodium will increase the thirst mechanism. Note: Many HF patients are at risk for hyperkalemia due to renal dysfunction, ACE-I or ARB, and aldosterone antagonists. These patients need instructed to avoid salt substitutes that contain potassium chloride.

8. Self Care Management • Last year’s competency focused on patient education skills related to self care management . • The self care skills with opportunity for improvement included: • Reliable system to remember to take medications. • Ability to read food labels and / recognize restaurant foods high in sodium. • Home scales with the ability to see and record daily weights. • Decision making ability to recognize reportable symptoms.

9. 2012 Focus • We want to build on what we learned about self care and focus on specific skills we can incorporate into practice to support self care. • There are three areas of patient education we want to focus on for 2012. • Documentation of a total of one hour of patient education for each heart failure patient. • Utilization of HF videos. • Involvement of primary caregiver in education sessions and discharge instructions.

10. 2012 Focus • There are also three specific self care skills we want to focus on during 2012. • Use of actual food labels when teaching patients about a low sodium diet. • Medication clarity. • Identifying where patients will record daily weights and what the patient response will be to an increase in weight gain.

11. Food Labels • To assist with patient education of self care skills we have created large laminated labels that can be used to teach patients how to evaluate the sodium content. Two sample labels are shown on the next slide. • Although we often tell our patients to eat a low salt diet, many patients do not have the skills necessary to implement a low salt diet into their daily lives. • Patients need to know that sodium means salt on a food label. • They also need to know that the amount of sodium listed is per serving. • A general rule is for patients to eat foods that are < 10% daily value of sodium per serving.

12. Sample Food labels: To Be Enlarged and Laminated for Patient Education

13. Medications • We want to use the SOAR method as a specific strategy to improve patient adherence and safety with prescribed medications. The SOAR method is a method developed specific for CCU competency and the HF population. • S = Stop medications. Please include all previous home medications the patient is to stop taking as part of the discharge instruction process. • O = Over the counter medications. Please instruct HF patients not to take any non steroidal over the counter medications like ibuprofen (Advil) or naproxen (Aleve). These medications can contribute to worsening renal function. • A = Affordability. Please inform the case manager, APN, or physician of any financial concerns. • R = Remember system. Please specifically ask the patient / caregiver to identify the system they are going to use to remember to take medications and remember to take their medication list with them to every provider appointment.

14. Daily Weight Recording and response • There are new daily weight log sheets available for patients to use. • Note: Patients should be encouraged to use their own system for recording daily weights if they already have one. • Patients should be instructed to use the first weight the morning after discharge as the starting weight. • Patients need to know to bring a daily weight sheet to each physician office visit. We are going to begin tracking how often patients bring a daily weight sheets to their first HF cardiology visit.

15. Daily weight recording and Response • It is also important for patients to know exactly what to do if they have a weight gain of > 2 lbs in one day or > 3 lbs in one week. • Patients need to know specifically which physician to call for an increase in weight gain. • Any patient seen by cardiology should have an appointment within one week of discharge. Patients should be instructed to call the cardiology office for any problems with their weight prior to the first follow up visit. • If a patient has not been seen by cardiology then they should be instructed to call their PCP or the physician who routinely manages their HF. • Some patients will have instructions to take additional diuretic in response to weight gain. • These patients will need extra education to assure they thoroughly understand how to dose the extra diuretic. • Taking additional diuretic may require extra potassium supplementation and / or more frequent lab draws. Please make sure any additional requirements are clear to the patient and caregiver.

16. General Patient Education Areas for Focus: One Hour of Patient Education • One hour of documented HF education • This is a new quality indicator for an initiative called Target HF which is offered through the American Heart Association. • The one hour of HF education is a new indicator because the study references below showed that one hour of nurse education at the time of discharge made a difference in patient outcomes. • Although we are not looking for one continuous time period for the hour of education, we are looking for a minimum of one hour total time of HF education. • Remember – this patient population is a high risk vulnerable patient population with very special education needs. • Data collection was imitated in the fall of 2011 and only 11/180 or 6.1% had a total of hour of HF education!! • Our goal is to achieve 85% after everyone has completed the competency modules. Koelling, T. M. , Johnson, M.L., Cody, R.J., & Aaronson, K.D. (2005). Discharge Education Improves Clinical Outcomes in Patients With Chronic Heart Failure, Circulation, 111, 179-185 doi: 10.1161/​01.CIR.0000151811.53450.B8

17. General Patient Education Areas for Focus: Video Use • We focused on HF video use during 2011 competency. Before competency we assessed our baseline use of video education in our HF population. • The next slide compares 5 months of pre competency video use with the next 5 months after we initiated the competency module. As you can see there was NO significant improvement. • Our goal for 2012 is that 75% our HF patients watch at least one HF video. We will share the results of this data with you during the annual competency meeting. Remember: It is not just showing the HF education video, you must ask the patients to teach back what they have learned.

18. HF Video Use Comparison Data

19. General Patient Education Areas for Focus: Education Including Primary Caregiver • The primary caregiver is often frail and sometimes is not able to frequently visit in the hospital (Hospital to Home Initiative). It may take a special effort to have them present for important information. • The primary caregiver is often responsible for meal preparation and medication administration. For this reason it is important that person is identified and involved in the education process. • We are asking everyone to do two things when educating the HF patient: • 1) Identify the primary caregiver • 2) Assure the primary caregiver is included in the education process. • This may require a telephone call or discussion with other family members in order to get the primary caregiver at the bedside for education.

20. Transitions of care

21. National transitions of care Coalition Patient’s Bill of Rights During Transitions of Care Transitions of care take place each time a patient goes from one health care provider or health care setting to another. Problems often happen during these transitions because information is not communicated. Patients and their family have the right to care transitions that are safe and well coordinated.

22. One important aspect of transitioning care with the HF patient is the first office visit post discharge. Transition of care In HF

23. Follow up Appointment • A vulnerable period for readmission is within the first week following discharge. • For this reason one of the new criteria for the American Heart Association Get with the Guidelines is for all HF patients to have a follow up appointment within one week of discharge. • To help meet this standard Kathy Evans has been working with the CVC APNs and with Colleen Motts (Aultman’s HF Coordinator) for non CVC patients to get an appointment within one week of discharge. • It is important that the provider, date and time be listed in the discharge instructions. It is not acceptable to say “Call Dr. _______ for an appointment in one week.”.

24. Our Success with one week appointments • Initial Aultman Hospital data collected in 2011 showed 28 of 103 patients or 27.2% of HF patients had a discharge appointment within one week of discharge. • January 2012 data showed that 39/84 or 46.4% of HF had a discharge appointment within one week of discharge. • There has been an improvement but we are not yet where we need to be. • If you are discharging a HF patient that is being seen by CVC (admitting or consulting) and there is not an appointment (date, time, and provider) for within one week of discharge please call the APN who is covering your POD. • If the patient is not being seen by CVC you can discuss with the discharging physician or page the HF nurse.

25. CVC Follow Up Appointments • HF patients being seen by a CVC cardiologist during their hospital stay will have their one week follow up appointment made in the HF clinic within the CVC office. • The HF clinic appointments are with an advanced practice nurse (APN) or physician assistant (PA) within the CVC practice. The APN and PA have access to a cardiologist during the HF clinic appointment if needed. • The most current data from the HF clinic show that 40% of the one week HF appointments are no shows.

26. CVC Follow Up Appointments • When discharging a HF CVC patient with a one week appointment, it is important to be accurate about whom the follow up appointment is with. The names of the APN or PA should be circled or written on the appointment card. • Also – please stress with the patient the importance of keeping this first one week appointment (even if it is within a day or two after discharge). • During this appointment the next appointment with the cardiologist will be made. • Additionally, a report will be sent to the primary care physician communicating all aspects of HF care.

27. Special Instruction regarding first HF clinic visit • There will be a one page handout to give to patients along with their appointment card, that describes the purpose of the first HF visit. • Please instruct patients and families to bring all their prescription and over the counter medications in a plastic or brown paper bag to their HF clinic appointment. • An important aspect of this first visit will be to review all patient medications.

28. FYI: New HF Certification • For anyone who might be interested – there is a new heart failure certification exam for nurses offered by the American Association of Heart Failure Nurses. • To be eligible for this certification a nurse must first have 30 hours of continuing education in heart failure to be eligible for certification. • You do not need to have a CCRN or PCCN certification to sit for the heart failure certification exam. • If interested check out the following website: http://www.heartfailurecertification.com

29. REMEMBER: We must not, in trying to think about how we can make a big difference, ignore the small daily differences we can make which, overtime, add up to big differences that we often cannot foresee. -Marian Wright Edelman

30. To Complete this module: • To complete this module please bring examples of the following to your annual competency meeting. Please include these examples in your professional portfolio. • Bring an example(s) of patient self care education you were involved in specific to: a) label reading for sodium, b) the SOAR method for medication adherence and compliance, or 3) instruction regarding recording and response to daily weights. • Bring an example(s) of how you have supported: a) involvement of the primary care giver, b) documentation of one hour of patient education, or c) viewing and teaching back of the HF videos.

31. Your Choice Activity: Choose One of the Activities to the Left.(your choice activity will be discussed at your competency meeting). • Obtain or maintain certification as a CCRN, and / or CMC, or HF certified nurse. • Submit a peer review written statement or a self reflective written statement (in your portfolio)demonstrating how you have shown clinical leadership in the area of teaching patients self care skills related to low sodium diet, medication adherence and safety, and or daily weight recording and reporting as discussed in this module. • Read an evidence based patient education journal article on heart failure management; identify how this article will change your practice and bring to your individual competency meeting. • Volunteer to serve on the Heart Center HF Work Group. Let Rhonda know if you are interested. Literature supports that professional nurses should take ownership in validating their own competency. Source: National Education Framework Cancer Nursing, 2008