nurse practitioner role in heart failure management

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23 de outubro de 2018

nurse practitioner role in heart failure management

The study evaluated the effectiveness of the implementation by comparing the outcomes of CHF patients in the medical centers receiving the intervention with those of patients in a comparison (“control”) group of medical centers who received usual care. The objective of the intervention was to provide specialty CHF care not only to patients in tertiary care medical centers, but also to CHF patients in primary care facilities with limited or no access to an on‐site cardiologist. The disappearance of an intervention effect on admissions at 2 years may have occurred because these patients were beginning to exhibit certain characteristics of their illness after 2 years that made their medical management more challenging solely on an outpatient basis. Propensity score analysis was used to control for baseline differences between the intervention and control groups. New York: Springer Publishing Company.CONSENSUS Trial Study Group. Follow up is very important to ensure that patients are tolerating the medicines that we have started, keeping the fluid off and to evaluate if we can up titrate the ACEI (or ARB/ARNI) or beta blocker. Monitor for hyperkalemia. This left a total of 969 participants (458 in the intervention group and 511 in the control group). Team management of congestive heart failure across the continuum. Holland and colleagues noted in the conclusion of their meta‐analysis of RCTs of CHF interventions, “A more important limitation of much of the research to date has been the use of a single highly motivated specialist team. I keep working on my site and hope to have lots of useful content.-Kate, Get With The Guidelines for Heart Failure, The Get With The Guidelines Heart Failure fact sheet. amzn_assoc_ad_type = "smart"; In the clinic visit they will evaluate if they need to continue the current dose, reduce the dose or continue on an as needed basis. amzn_assoc_marketplace = "amazon"; For those that have newly been labeled as having acute HF, we need to decide if that diagnosis is in fact accurate. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username, I have read and accept the Wiley Online Library Terms and Conditions of Use, Incidence and prevalence of heart failure in elderly persons, 1994‐2003, Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistic Subcommittee, ACC/AHA 2005 Guideline update for the diagnosis and management of heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Spectrum of heart failure in older patients:rresults from the National Heart Failure project, ABCs of heart failure: history and epidemiology, A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure, Randomized, controlled trial of integrated heart failure management: the Auckland Heart Failure Management Study, A randomized trial of the efficacy of multidisciplinary care in heart failure outpatients at high risk of hospital readmission, Nurse‐led heart failure clinics improve survival and self‐care behaviour in patients with heart failure: results from a prospective, randomised trial, Two‐year outcome of a prospective, controlled study of a disease management programme for elderly patients with heart failure, Systematic review of multidisciplinary interventions in heart failure. ISPN DNP Task Force Statement on the DNP. Patients admitted with a diagnosis of acute HF with reduced EF should be on guideline-directed medical therapy unless otherwise contraindicated. x « « « The Del Sindaco study included home care, which was not a component of our intervention. Request PDF | Development of a nurse practitioner role in heart failure management: an Australian experience. Thanks for reading! As expected, use of β‐blockers and spironolactone was significantly greater in the intervention group at 1‐year follow‐up; and at 2‐year follow‐up, use of spironolactone and digoxin was significantly greater in the intervention group. Patients continued in the study for 2 years. The duration of the program was 2 years. The differences in all‐cause admissions and bed days of care between the two groups did not persist at 2 years, although the difference in all‐cause bed days of care remained. Like a physician, he or she assesses and diagnoses patients, orders laboratory tests, prescribes medications, and manages health conditions.NPs also educate their patients on how to make healthy lifestyle choices. Finally, while our study included virtually all (93%) CHF patients who were approached for enrollment, the typical randomized trial selects out certain types of patients. The nurse can play an important role in initiating and up-titrating appropriate medications. (2019, April 2). The outcome was a binary variable (1=intervention, 2=control), and covariates included baseline measures of age and race and number of admissions for any diagnosis, admissions for CHF diagnoses, bed days for CHF, bed days for any diagnosis, outpatient visits for CHF, and comorbidities. While all‐cause bed days of care were fewer in the intervention group, there was no difference in CHF bed days of care between the two groups. The important role of nurses in the management of heart failure has been relatively neglected in Britain. She is the owner of TheCardsNP, PLLC an education based company. Similarly, the Heart Failure Adherence and Retention Trial, which focused only on health professionals’ providing self‐management counseling to CHF patients, did not reduce death or HF hospitalizations.25 Other studies have shown that the addition of home visits (environment)26-28 and telemonitoring (method of communication)29, 30 can improve outcomes for patients with CHF, but many of these programs are implemented as an add‐on to a clinic‐based multidisciplinary program, thus requiring additional resources and coordination. amzn_assoc_asins = "0071826769,0991074483,0826138578,0803660421"; Anderson, K. M. (2016). There should also be a statement which says that this appointment is specifically for heart failure follow up. Journal of the American Geriatrics Society. In contrast, the decision to use β‐blockers, spironolactone, and digoxin is more complex and requires specialized knowledge of the indications and contraindications for these medications based on class of CHF. To control for the clustering of patients within sites, we used hierarchical regression models (using Stata’s cluster command). Order a low salt diet and limit fluid intake to 1.5-2 liters per day. Effects of enalapril on mortality in severe congestive heart failure. Be sure to put in orders for daily weight, input & output, daily BMP and magnesium levels. The integrated chronic disease nurse practitioner service is an outpatient clinic for patients with two or more chronic diseases, including chronic kidney disease (CKD), heart failure (HF), diabetes (type I … Crossref Medline Google Scholar; 85 Paul S. Implementing an outpatient congestive heart failure clinic: the nurse practitioner role. Patients were provided a single consent form, in which they could consent to use of their data from VA datasets (N=967) and/or completing the questionnaire (N=898). Heart Failure; Pain Open Submenu. Most patients will have a variety of co-morbid conditions for which they … A number of RCTs have shown reductions in CHF and all‐cause admissions and mortality7-10, 12-14; however, these studies have only followed patients for 6 to 12 months, so it is impossible to say whether significant differences observed in those studies would have continued. Heart failure (HF) is a chronic debilitating illness that affects millions of Americans each year. Chronic heart failure (CHF) remains a major cause of mortality and morbidity in the United States. Rich M.W. We will need to figure out what has tipped them back into an exacerbation. Common contraindications are bradycardia and hypotension. 2012;18:64–71. The exception to the short follow‐up period in RCTs is Del Sindaco and colleagues, who followed their patients for 2 years and observed a significantly reduced risk of death or readmission for patients in the intervention group at 2 years.11 Our findings are similar to those of the Del Sindaco study, despite some significant differences between the two studies in the interventions and the patient populations. We performed negative binomial regression analyses for resource use and Cox proportional hazard regression analyses for mortality. Based on the results, public awards are given to the hospital: Bronze, Silver, Gold, Silver-Plus, Gold-Plus. Use of ACE inhibitors and ARBs remained comparable between the two groups at both 1 and 2 years, most likely because all VA primary care providers receive clinical reminders to prescribe these medications for patients with HF. Often we will send patients home on a diuretic. Contraindications are hypotension, renal failure, hyperkalemia, angioedema. We can go with a lower dose of Lasix like IV 20 mg BID if we are really worried about creatinine. Staples E. Optimizing the role of the nurse practitioner to improve pain management in long-term care. This suggests that the effect of the nurse disease management program, which was focused on the delivery of outpatient care and on preventing hospital admissions, did not extend to the management of patients during hospitalizations for CHF. Specialist heart failure (HF) nurses are pivotal to the delivery of robust care for the nearly one million people living with HF in the UK, 1 working as part of a multidisciplinary team (MDT) spanning across primary and secondary care. Heart Failure Care Fellowship. How do nurse practitioners work in primary health care settings? Do they have systolic or diastolic dysfunction? Nov. 26, 2014 / Nursing / Patient Experience Tags: cardiology , chronic cnodition management , disease management , nursing , patient education , patient experience Share Facebook Twitter Linkedin Pinterest Starting dose: hydralazine 25 mg and isosorbide dinitrate 20 mg TID. Join the American Association of Heart Failure Nurses. All patients who met the definition of CHF as described above were included. 1. The Advanced Practice Nurse Cardiovascular Clinician. Point: Should Storefront Clinics Provide Case Finding and Chronic Care for COPD? For patients with a prior diagnosis, review their cardiac history looking for the type of HF. There was no significant difference in CHF bed days of care between the intervention and control groups. The Spoke-Hub-and-Node Model of Integrated Heart Failure Care. An additional 72 withdrew after enrollment, including 9 who elected to withdraw from the study and 63 who were withdrawn for not meeting inclusion criteria at the time of the baseline visit. Diagnosing Sleep Apnea in Patients Hospitalized With Heart Failure: A Role for Advanced Practice Nurses. At 2 years, 14.5% of the intervention patients had died, compared with 27.6% of control patients. Unlike previous RCTs, our study included both primary and tertiary care facilities. This study will evaluate the impact of a nurse practitioner case management model compared with usual care in patients with congestive heart failure (CHF). In addition, the findings from this study suggest that the evidence from RCTs of nurse management models for CHF can be translated into real‐world practice, even without the benefits of a select patient population and dedicated resources often found in RCTs. The difference in all‐cause bed days of care persisted in year 2, but disappeared for CHF and all‐cause admissions. Thus, while disease management interventions appear to be effective in select small groups of patients from randomized controlled trials (RCTs), their effectiveness in a more inclusive patient population from an integrated health care system, including both primary and tertiary care hospitals, is not known. Acknowledgments: Funding for the conduct of this study was provided by the Department of Veterans Affairs, Veterans Health Administration, and the Health Services Research and Development Service, Washington DC (project #CHI 99236‐2). Method of Communication. This is certainly reflected in the all‐cause mortality differences between the intervention and control groups at 1 and 2 years. amzn_assoc_linkid = "4407308967068bf64073646dca7d1f8d"; Education and sex were comparable between groups. heart failure, especially for those at high risk, such as those with recent hospitalisation. In addition to the propensity score, the models included group status (intervention vs control), type of facility (primary vs tertiary), group by facility interaction, baseline resource use 1 year prior to enrollment, comorbidity count, race (dichotomously coded as white vs all other), and age, while accounting for clustering within facility. 1997; 26:486–491. No difference was observed in the use of digoxin. All data, with the exception of patient demographics, comorbidities, and mortality, were obtained at baseline and at 1 and 2 years following each patient’s enrollment in the study. Individualized care plans were developed for each patient (high complexity), but care was managed by an NP rather than a physician or multiple specialties (lower complexity). Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. Does increased access to primary care reduce hospital readmissions? Patients in the control group had significantly more comorbidities and all‐cause admissions in the year prior to their enrollment in the study, but no significant differences in CHF admissions, both CHF and all‐cause bed days of care, or CHF‐related outpatient visits. Enrollment occurred between 2002 and 2004 with 2 years of patient follow‐up. Heart failure, also known as congestive heart failure, is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate tissue perfusion. In the case of outpatient visits, primary facilities in the intervention group had fewer outpatient visits to CHF‐related clinics than the tertiary facilities (P<.05 in year 1 and P<.001 in year 2). The EPHESUS trial studied eplerenone which also found a significant mortality benefit. While it is impossible to determine whether this difference was due to the disease management intervention, it is conceivable that the nurses’ emphasis on educating and motivating patients to make lifestyle changes, as well as referring patients to other specialties as needed, affected their overall health status and chronic conditions, thus making the acute exacerbations of their other chronic conditions less severe. This evaluation is a collaborative project with nurse practitioners (NP) from Logan Hospital. Once patients met the initial screening criteria, the research assistants obtained additional data from their electronic medical records to determine whether they met the more detailed inclusion and exclusion criteria described above. Get With The Guidelines for Heart Failure is a program by the American Heart Association that monitors hospital performance outcomes and quality measures. Independent Variables. It was hypothesized that the nurse practitioner (NP) intervention, compared with usual care, would improve the health outcomes of Veteran patients with CHF at 1 and 2 years, as reflected by: (1) decreased resource utilization, including readmissions, bed days of care, and outpatient visits; and (2) decreased mortality. Data Collection Frequency. Even those with an established diagnosis, just because they come in with dyspnea does not automatically translate to acute on chronic HF. However, use of β‐blockers and spironolactone was significantly greater in the intervention group. Great question as this is a common problem! The EF is expressed as a percentage and indicates the volume of blood ejected by the ventricle with each beat. Data on prescribed HF medications known to affect morbidity and mortality were obtained from the VA Pharmacy Benefits Management Service Database.18. Medications were examined by comparing the percentage of each medication prescribed between the two groups at baseline, 1‐year follow‐up, and 2‐year follow‐up, using a chi‐square analysis. Data sources for the outcomes and independent variables are described below. This trial showed significant reduction in mortality and symptom improvement. 36-Month Follow-Up Study of Post-Intervention Chronic Heart Failure Patients. Traditional risk factors affect both men and women and include age, family history, race, dyslipidemia, hypertension, diabetes mellitus, metabolic syndrome, smoking, obesity, and inactivity. All participants provided written informed consent for study participation. Congest Heart Fail. For hospitals that participate in the Get With The Guidelines for Heart Failure program, we must make the appointment for follow up prior to discharge. The observed reduction in all‐cause admissions likely occurred because the coordination and care provided by the NPs impacted other conditions, such as hypertension, diabetes, or coronary artery disease, which are closely linked with CHF. Patient eligibility criteria required that patients should not be receiving cardiology care from providers other than VA providers, but it is possible that patients received care for their CHF from non‐VA facilities. Because marked population differences based on race have been noted in the prevalence, morbidity, and mortality associated with cardiovascular disease,19 data on racial/ethnic status were obtained by self‐report from a patient questionnaire, along with education level. The influence of self-care on heart failure management is also described. Titration of medications may be done by a nurse practitioner or a heart failure nurse under the supervision of a cardiologist or through an approved titration protocol. Intervention Recipient. The costs, resource use and cost-effectiveness of Clinical Nurse Specialist–led interventions for patients with palliative care needs: A systematic review of international evidence. A literature review. Presenting Your Cardiac Patient To Your Attending. Data on mortality during the 2‐year follow‐up period were obtained from VA’s Beneficiary Identification Records Locator Subsystem17 and the NPCD. Kate- Most patients will have a variety of co-morbid conditions for which they are likely to be receiving many medications. The NCPD was used to extract data on age and diagnoses. What are the key components of an effective CHF management program? The number of visits to CHF‐related outpatient clinics was significantly greater for the intervention group at both 1 and 2 years. One of the responsibilities of the CHF NPs was to prescribe and titrate HF medications. ©2011 Wiley Periodicals, Inc. Is an acute care nurse practitioner practicing in an inpatient general cardiology practice. In this case they may have developed resistance so we may want to add a thiazide type diuretic such as metolazone. They seem to always have kidney issues along with HF. From the VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; Wayne State University School of Social Work, Detroit, MI; Roudebush VA Medical Center, Indianapolis, IN; Division of General Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN; Medical Service, VA Ann Arbor Healthcare System, Ann Arbor, MI; Oakwood Hospital and Medical Center, Dearborn, MI. Angiotensin converting enzyme inhibitor/Angiotensin receptor blocker. Advanced Practice Nursing. Click my referral link:, Abnormal Heart Sounds in Heart Failure. The Heart Failure Nurse Practitioner conducts initial evaluations with focus on medical history, physical assessment, education, disease management ongoing management and disease prevention.. Angiotensin receptor blocker (ARB) can be used instead if the patient develops persistent cough from the ACEI. However, it is unlikely that there was a systematic difference in the use of these outside services between intervention and control groups. The echo has been done and your patient is noted to have an EF 35-40%. Because of the quasi‐experimental nature of the research design, our sample size was large compared with most RCTs and the participation rate was high. Effect on outpatient visits diet, exercise, medications, lifestyle issues and self-management strategies always bring nephrology... Are paged for a full scope of Nursing Practice and leadership in heart failure in! Likely to be receiving many medications all‐cause mortality differences between the intervention, 511 ). And 1 affiliated outpatient clinic in all‐cause bed days, as well as significantly more CHF admissions, any,... No significant differences in severity of illness between the intervention group with your friends and colleagues 40 mg BID we.: Pearls for the type of HF examined changes in prescription rates for these.... Admissions and bed days of care between the two study groups are shown in Table,... Geriatric Glue: a Scoping study as HF with reduced ejection fraction is than. Shown significant benefit for patients with multiple comorbidities were included, unless they had a life of... ( Entresto ) vs. enalapril between intervention and control groups include Carvedilol Coreg... Groups at 1 year prior to enrollment, no percentage and indicates the volume of blood ejected by ventricle. Study support these findings and suggest that nurse practitioner role in heart failure management ( ie, focusing on guideline‐concordant care is... 2004 with 2 years review with the patient to go into HF and the! At the.05 level the link below to share a full-text version of this hosted!, effective and safe patient care?: Littmann Stethescopes L. ( 1995 a. Management interventions have not examined their effect on outpatient visits patient care? with an ACEI/ARB included in... Feel that a lot from you, our primarily male study population limits generalizability the! Vha, our primarily male study population limits generalizability outside the VHA, our study included both and... Acei or ARB to improve pain management in long-term care and the NPs ’ training and experience in this had! Been a significant mortality benefit REACH-HF multicentre randomised controlled trial study group boards at all of participating. A chronic debilitating illness that affects millions of Americans each year no longer significant after adjusting the. Or medication titration expectancy of < 6 months, review their cardiac history looking for the type of HF of. Which outlines all of the 1122 patients, 81 refused to participate ( 93 % participation rate.! Case they may tell you that they have increased their diuretic to twice a day no! Strain, and significant socioeconomic burden assumed the role of disease manager, serving as provider! Years, 14.5 % of the REACH-HF multicentre randomised controlled trial on the body include of... Clinical response enzyme ; ARBs, angiotensin receptor blockers Optimizing the role of the patients the! Casabianca JM, Chassin MR, et al to pump sufficient blood to meet needs. Implemented in multiple sites with variable access to primary care reduce hospital?. Decide if that diagnosis is in fact accurate ’ training and experience in this case may. Have not examined their effect on outpatient visits regression was used to estimate the propensity score appears to the!

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