Utah Diabetes Telehealth Program Heart Failure by Kismet Rasmusson, FNP-BC, FAHA February 2010 http://health.utah.gov/diabetes/telehealth/telehealth.html

1. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Heart Failure
Transitions in Care
Kismet Rasmusson, FNP-BC, FAHA
FNP-
February 17, 2009
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Feb 14-20, 2010
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Objectives
•To understand the
impact heart failure has
on healthcare delivery
•To learn strategies to
provide best practices for
heart failure care
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1

2. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Case Study
Mr. C is a 68 year old man with cough and shortness of
breath whose MD squeezes him in to his busy schedule.
He was hospitalized 3 weeks ago with CHF, discharged on
captopril and a “no added salt diet,” with encouragement to
see his MD in three weeks.
His MD does not have information about the
hospitalization.
On exam, Mr. C is told by his MD he still has “some heart
failure,” is encouraged to continue cutting salt out of his
diet, and told to call back if he is not better.
Two weeks later, Mr. C calls 911 because of severe
breathlessness and lower extremity swelling, and is
admitted to the hospital.
A more complete history in the hospital reveals that he has
been taking the captopril only as needed because it seems
“strong,” and he has never added salt to his diet, so his diet 1350g.4
has not been changed.
Heart Failure
Scope of Problem
• Most common cause of hospital admission in patients over age 65
years
• Accounts for > 1 million hospitalizations/year
• Accounts for more than 6 million hospital days/year
• Accounts for $37 billion in costs annually in the U.S.
• Re-hospitalization or death approximately 50% within 6 months
• Median length of stay 5 - 6 days
• In-hospital mortality 5 to 8%
Thom et al. Circulation 2006 February 14;113(6):e85-151. Felker et al. Am Heart J 2003;145(2):S18-S25. Felker et al. J Card
Fail 2004;10:460-466. Lee et al. JAMA 2003;290(19):2581-2587. Hunt SA et al. ACC/AHA Guidelines for the Evaluation and
Management of Chronic Heart Failure in the Adult. 2001. Graves EJ, Gillum BS. 1994 Summary: National Hospital Discharge
Survey. National Center for Health Statistics; 1996.
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Heart Failure
… is a serious public health concern
… is a substantial cause of morbidity and mortality and
health expenditures
… evidence-based therapies have been demonstrated
evidence-
to improve outcomes
… requires tremendous efforts of care across the
continuum
www.myamericanheart.org 1350g.6
2

3. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Heart Failure Hospitalizations
70% due to worsening chronic HF
With either preserved or reduced LVEF (46-54%)
(46-
25% due to de novo HF
5% due to advanced HF
Refractory to therapy
Severe LV systolic dysfunction
Low-
Low-output state
Mean age 73 years
Age > 75 years in 50% of admissions
52% female
Georghiade. Circulation 2005;112:3958-3968
Adams. Am Heart J 2005;149:209-216 1350g.7
Age-Adjusted Heart Failure Hospitalization Rate
National Hospital Discharge Survey, 1979-2004
1200
1000
HF Diagnosis Listed
800
000
Men 1st
Per 100,0
Women 1st
600
Men 2nd+
400 Women 2nd+
200
0
1979 1984 1989 1994 1999 2004
Fang et al. J Am Coll Cardiol 2008;52:428-434
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Comorbidities in Patients With HF
45 42
40
35 31 32
28
30
ents (%)
25
20
18
Patie
20
15
14
15
11
10
6
3 3
5
0
Fonarow et al. Arch Intern Med. 2007;167:1493−1502. Abraham et al. J Am Coll Cardiol 2008;52:347-356.
The OPTIMIZE-HF Registry [database]. Final Data Report, Duke Clinical Research Institute, July 2005.
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3

4. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Heart Failure Hospitalization Rate
National Hospital Discharge Survey, 1979-2004
4000
3500
3000
000
2500 Men < 65 Yrs
Per 100,0
Men > 74 Yrs
2000
Women < 65 Yrs
1500 Women > 74 Yrs
1000
500
0
1979 2004
Fang et al. J Am Coll Cardiol 2008;52:428-434
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LVEF in Hospitalized HF Patients
5,000
Documented LVEF Measured Prior to or
During Hospitalization
4,183 15,215/36,115 (42%) with LVEF > 40%
4,000 3,814
3,506
3,193
Patients (n)
2,924 2,947
3,000 2,812 2,806
s
2,345 2,331
2,000 1,833
1,270
1,137
1,000
553
274
44 100 32 10 1
0
0- 6- 11- 16- 21- 26- 31- 36- 41- 46- 51- 56- 61- 66- 71- 76- 81- 86- 91- 96-
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Left Ventricular Ejection Fraction (%)
Fonarow GC, et al. J Am Coll Cardiol. 2007;50:768−777. 1350g.11
Outcomes
P=NS
7
6.0
5.7
6
P=NS
P<.0001
5
4.0 4.0 3.9
4
2.9 LVSD
3
2 PSF
1
0
Length of Stay, Length of Stay, In-Hospital Mortality
Mean (days) Median (days) (%)
PSF = LVEF ≥40%; Fonarow GC, et al. J Am Coll Cardiol. 2007;50:768−777.
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4

5. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
STAGES OF HEART FAILURE
*ACCF/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. 2009
Stage A Stage B Stage C Stage D
IDENTIFYING EACH STAGE….
• High blood pressure • Prior heart attack • Known heart failure • Marked symptoms
• Atherosclerosis • Evidence of enlarged • Known symptoms: despite optimal
• Diabetes or thickened heart Shortness of breath therapies
• Obesity • Valve disease Fatigue, reduced
• High cholesterol activity tolerance
• Sedentary lifestyle
• Family history of
cardiomyopathy
• Use of cardiotoxins
• Continue stages
TREATING EACH STAGE….
A, B • Continue stages A, B,
• ACE-I or ARB and C
• Treat high BP • Continue stage A • Beta-blockers • IV inotropes
• Smoking cessation • Start medications: • Diuretics • Nesiritide
• Treat lipid disorders ACE-I or ARB • Spironolactone • Heart transplantation
• Exercise Beta-blockers • Digitalis • Mechanical devices:
• Treat diabetes • Internal cardiovertor • Hydralazine/ISDN LVAD
• Avoid illicit drugs defibrillator • Biventricular pacing • Hospice care
• Limit excess alcohol +/- defibrillator
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The Course of Heart Failure
Complete Care = Heart Failure Care + Supportive Care
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Goodlin et al, J of Card Fail, Vol 10. 2004
Successful Heart Failure Management
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5

6. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Algorithm for ADHF
CONGESTED Goals of Therapy HYPOPERFUSED
↓PCWP and Diurese Unload and ↑SV/CI ↑CO/BP/renal perfusion
rales, edema, JVD, S3 mixed presentation low BP, cool, clammu
CI/SV adequate
d ↑PCWP,
↑PCWP ↓CO ↓CO, ↑↓PCWP
Inotropes
Diuretics
Vasopressors
Diuretics & vasodilator Combined therapy
Loop bolus Nesiritide Diuretic +/- vasodilator
Combo Agents
NTG IABP
Cont. infusion
Nitroprusside Consider Inodilator VAD
Ultrafiltration / HD Milrinone, dobutamine Transplant?
Compilation of ACC/AHA, HFSA and ESC Guidelines 1350g.16
Mainstay of Heart Failure Management
Medical & device therapies proven to reduce
symptoms, improve mortality and
readmissions…
• ACE inhibitors (ARBs)
( )
• Beta blockers
• Aldosterone antagonists (spironolactone)
• Digoxin
• Diuretics
• ICDs
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6

7. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Getting the “Congestion”
out of Heart Failure
Pharmacologic therapy:
Diuretics
Vasodilators
Natriuretic peptides
p p
Inotropes
Avoidance of NSAIDs/COX II and some oral
hypoglycemic agents
Nonpharmacologic therapy:
Sodium and fluid restriction
Ultrafiltration
Hemodialysis 1350g.19
JCAHO & CMS
Heart Failure Core Performance Measures
Assess left ventricular function;
• prior to admission, during hospitalization, or plan after
discharge
Prescribe ACEI or ARB for LVEF < 40%;
• document contraindications to both, when not prescribed
both,
Provide discharge instructions:
Provide smoking cessation counseling
Document
Document
Document…
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Recommendations for the Hospitalized Patient – New
Recommendations
2009 Focused Update Recommendations
17. Comprehensive written discharge instructions for all patients with a
hospitalization for HF and their caregivers is strongly recommended,
with special emphasis on the following 6 aspects of care:
- diet discharge medications, with a special focus on adherence,
persistence, and
- uptitration t recommended d
tit ti to d d doses of ACE inhibitor/ARB and BB
f i hibit /ARB d
medication,
- activity level,
- follow-up appointments,
- daily weight monitoring, and
- what to do if HF symptoms worsen. (Level of Evidence: C)
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7

8. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Indications for the Cardiac Resynchronization
Therapy
Moderate to severe heart
failure (NYHA Class
III/IV)
QRS ≥ 120 ms Right Atrial
g
LV ejection f ti ≤
j ti fraction Lead
35%
Symptomatic despite
Left Ventricular
stable, optimal medical Lead
therapy
Right Ventricular
Lead
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22
Sudden Cardiac Death
Heart enlarges
Susceptible to cardiac dysrhythmias
When sustained VT/ VF, sudden death occurs
Internal Cardioverter Defibrillators:
Analyze, pace terminate
shock lethal arrhythmias
reduce mortality
ICDs save lives
© 2008 Fitzgerald Health Education Associates, Inc. 23
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8

9. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Stage D Heart Failure Therapies
LVEF < 25%?
Poor toleration of ACEI, ARB and/or Beta blocker?
Estimated life expectancy < 2 yrs?
Repeated hospitalizations?
Progressive symptoms?
Poor oxygen consumption?
Elevated filling pressures?
Requiring escalating diuretics?
q g g
Consider referral for Consider referral for
cardiac transplantation destination LVAD
if physiologically <65 yo if physiologically > 65 yo or
non-transplant candidate
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25
Renlund & Kfoury.
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NEJM 2006;355:1922
UTAH Cardiac Transplant Program 1985-2010
@ Intermountain Medical Center
Number of Transplants: 1058
1 & 3 year survival: 100% •LDSH/IMED
Alive/dead = 50/50 @ 12 years
•PCMC
Number of publications: >300
Research dollars: >$7,800,000
$ •VAMC
Trainees: 57 •UUHSC
UNOS certification
CMS certified since 1988
JCAHO accredited
March 2009:SRTR
www.ustransplant.org
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9

10. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
The Utah Artificial Heart Program
www.uahp.com 1-877-784-2226
Leading center in the US
>20 years of experience in artificial heart
technologies
Multidisciplinary approach
Acute, temporary support
Bridge to transplantation
Destination therapy
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End-of-Life Considerations
Discuss prognosis and chance of survival
Discuss advanced directives, and how this may change with
changing clinical status
Discuss option of deactivating an ICD
Provide continuity of care between inpatient and outpatient
Use strategies for palliation of symptoms
g p y p
Diuretics
Inotropes
Nitroglycerin
Oxygen
Anxiolytics
Morphine
29
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Patient Support Network
Utah
Artificial
Heart
Referring Program Administrative
Physician Representative
Cardiac
Community
Surgeon
Patient
Clinical Interventional
Research Cardiologist
Critical Heart
Care Failure
Team Team
Heart
Transplant
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10

11. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Heart Failure at
Intermountain Health Care
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Intermountain Health Care
Heart Failure Prevention and Treatment
Program
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HFPTP—UTAH Cardiac Transplant—UAHP
at Intermountain Medical Center
BC Cardiothoracic Surgeons –4 Pharmacists – 6
BC HF/Transplant Cardiologists – 3 Pathologists – 3
BC Intensivists – 4 LCSWs – 1
Nurses CV Anesthesiologists- 6
Anesthesiologists-
HF/Transplant Interventional/EP cardiologists- 11
cardiologists-
– NPs/PAs – 7 Full diagnositic support (cath/EP/echo)
g pp ( )
– Nurse Coordinators – 5 PT/OT/ST
Histocompatability & Immunogenetics
– MA – 3
Lifeflight
– CV Research Coordinators-2
Coordinators-
Intermountain Donor Services
– HF care manager
Financial Specialist
UAHP
Admin. Support
– Nurse Coordinators – 5 – Operations officer
– Outreach Nurse Coordinator – 1 – Nurse administrator
– Research Nurse – 1 – Director of cardiovascular services
– Bio-Engineers – 4
Bio-
– Nurse administrator 1350g.33
11

12. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Intermountain Healthcare’s
Cardiovascular Clinical Program
Extends HF care throughout the system
HF disease management
Targeted goals and JCAHO/CMS core measures
Provider/nursing HF education
– Clinical pearls emailed monthly
Cli i l l il d thl
Standardized tools
– Admission orders, computerized DCM program,
standing orders, patient tools, reminders
Outcomes monitoring
– By provider, unit, hospital, region, system
HF Liaisons at each hospital
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Institutional Heart Failure Discharge Medication
Program Reduces Readmissions and Mortality
100 95 Pre-Intervention (n = 11,038)
Post-Intervention (n = 8,045)
Treatment Rat (%)
65 HR 0.80
tes
P < 0.0001
50 46
HR 0.77
38 P < 0.0001
23 18
0
ACEI Rx Readmissions 1-year Mortality
Intermountain Health Care: 10 Hospitals Pre 1/96-12/98 (n = 11,038) to 1/99-3/00 (n = 8,045)
Pearson TA. Circulation. 2001;104:II–838. 1350g.35
Intermountain’s Heart Failure Tools
Admission orders
Discharge orders (computerized)
Cardiovascular pharmacists
Heart failure care manager
Heart failure “liaisons” at each hospital
Email updates; readmissions, IV diuretics, EF
Reminder tools; sticker, posters
Education-
Education- CME, Nursing, Clinical Pearls
Heart Failure Prevention and Treatment Program; 801-507-4000
801-507-
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12

13. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Pharmacist’s Role
Identify heart failure patients
Educate physicians, nursing, care managers
Monitor for appropriate medication therapy
Monitor
M it reports for accuracy
t f
Be creative to meet facilities specific needs
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Identify Pts & Track HF Measures
List of all admissions
Review Dx:
Sure bets: HF, CHF, SOB, pleural effusions
Could be: CP, syncope, AMI, arrythmias, PE
Possibly HF f ti
P ibl HF: fatigue, pneumonia, cough
i h
Review records; chart &/or computerized
Review w/ providers if questions
Track 4 HF measures
Have HF diaries, pt ed manuals, DVD/videos ready
Use CV discharge form
Care managers and pharmacists
Other tools
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13

14. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
HF
Heart Failure
Primary Dx
NO YES
~ Similar Dx that could be ~ Teach MAWDS with packet & video
coded HF (i.e. Hypoxia, SOB, ~ Check for ACE/ARB
Edema, increasing fatigue or ~ Check Echo
~Teach smoking cessation
lethargy)
~ Call dietician & pharmacy for teaching
NO YES ~ Document in Tandem, Discharge sheet, and
charge sheet, and
on karedex
ts
t’s been done
done. ~ Give MAWDS Steps ~ Ask Doctor if HF
flyer & teach
~ Document in Tandem,
Discharge sheet, and on
karedex YES NO
~ Teach MAWDS with video/packet ~ Give MAWDS Steps
~ Get Echo unless one has been done ~ Document in Tandem,
~ ACE or ARB or contraindication Discharge sheet, and on
~ Teach smoking cessation karedex
~ Call pharmacy & dietician
~ Document teaching in Tandem, Discharge
sheet, and on karedex
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Self-management tools:
Diary
Patient education manual
Video/DVD
Website
2008 Classes 1350g.41
HF Education 2002
6 week-outpatient HF self-management curriculum offered to any patient
week- self-
Pre-
Pre-test and post-test given to assess knowledge
post-
Pre-
Pre- and post-class determination of use of health resources (ED or office
post-
visits, hospitalizations
34 of 37 completed the lecture series
Average pre-test score 75% post-test 97%
pre- 75%, post-
All felt the series improved their understanding of HF
90% reported feeling like they could improve self-management and QOL after
self-
the lecture series
The majority felt the class would help them follow their provider’s treatment
plan
Patients had fewer ED visits and hospitalizations, and had a slight increase in
office visits.
Rasmusson et al. J of Card Fail. Aug 2002:8(4),S5. 1350g.42
14

15. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
MAWDS…makes a difference!
1000
750
500
p=0.027 250
n=523 n=983
0
• 1,506 cases met the JCAHO/CMS eligibility requirements for receiving Discharge
Instructions 2002 – 2004. Subjects receiving Discharge Instructions are more likely to be alive 1 year following discharge
than those who don’t [Hazard Ratio: 0.79, p-value: 0.027, adjusted for age, gender, severity, los ]
Supplement to the Journal of Heart and Lung Transplantation
Volume 24, number 2S, S68, 79, February 2005. 1350g.43
Heart Failure Core Measures:
An Intermountain Healthcare Analysis showed an: 1. Assess left ventricular function:
Incremental 1-year Survival Benefit with
2. Prescribe ACEI or ARB for LVEF <
Better Adherence to JCAHO Heart Failure 40%:
Core Performance Measures*
3. Provide discharge instructions:
4. Adult smoking cessation
•G0: adherence to 0 HF measure
•G1: adherence to 1 HF measure
•G2: adherence to 2 HF measures
•G3: adherence to 3 HF measures Kfoury et al. J of Card Fail. 2008; 14(2)95-102.
•G4: adherence to 4 HF measures
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Public Reporting on Heart Failure Care
http://www.hospitalcompare.hhs.gov
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15

16. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
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Heart Failure
Disease Management
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Care Gap for
Patients with CHF
Percent of CHF patients given: Average for all Top 10% of
hospitals hospitals
reporting in the nationwide
US
ACE i hibi
inhibitor or ARB f l f
for left 81% 100%
ventricular systolic dysfunction
(LVSD)
Assessment for left ventricular 81% 95%
function (LVF)
Discharge instructions 54% 89%
Smoking cessation advice/counseling 76% 100%
CMS and HQA data from 1/05 through 12/05 1350g.48
16

17. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
HFSA 2006 Practice Guideline (8.7)
Heart Failure Disease M anagem ent
Patients recently hospitalized for HF
and other patients at high risk
should be considered f referral
h ld b id d for f l
to a com prehensive HF disease
m anagem ent program that delivers
individualized care.
Strength of Evidence = A
Adapted from : Adam s KF, Lindenfeld J, et al. HFSA 2006 Com prehensive 1350g.49
Heart Failure G uideline. J Card Fail 2006;12:e1-e122.
ACC/AHA HF Guidelines
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HF Disease M anagem ent and the
Risk of Readm ission
1.1 Ekman
Risk 1
Ratio
0.9
0.8 Lasater
Stewart
Jaarsma
0.7 Rich Rauh Venner
Cline
0.6
Naylor Fonarow
0.5
Sum m ary RR = 0.76 (95% CI .68-.87)
Sum m ary RR for random ized only = 0.75 (CI = .60-.95)
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17

18. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
HF DM Lessons Learned
Success will depend on your structural support
Administrative/operational
Financial
Information technology
RNs, d
RN advanced practice clinicians, MDs
d ti li i i MD
Support staff
Access to urgent care and to HF specialists
Supporting this process
Tele-
Tele-management and remote monitoring
Care manager phone calls, twice in first month post-discharge
post-
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Summary:
Guiding Appropriate Heart Failure Care
Identify all patients with heart failure
Assess ventricular function
Prescribe appropriate medical therapies
Include non-pharmacologic therapies
non-
Ensure appropriate follow up plans been made
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Heart Failure Quality Improvement
Collect baseline data or use existing data source
i.e. collect data with HF nurse, case manager, PharmD, or medical
student, etc.
Select a champion, appoint a team
Develop (adapt) treatment algorithms, preprinted orders,
discharge forms
Communicate with key departments to get buy-inbuy-
Present at grand rounds, lectures, and staff in-services
in-
present rationale for program and tools
review prior successes and failures
lead discussion regarding recommendations on protocol improvement
Implement program to close gaps in care
Repeat cycle frequently (every quarter) = CQI
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18

19. LCAC Presentation
(FINAL BMS-SANOFI 10-17-01)
Key Elements to
Quality Improvement
Why Do Some Hospitals Succeed?
Access to current and accurate data on
treatment and outcomes
Have stated goals
Administrative support
Physician champion, support among clinicians
Use of pre-printed orders, care maps
pre-
Use of data to provide feedback
Willingness to modernize, change with the times
Bradley EH et al. JAMA. 2001;285:2604–2611. 1350g.55
Resources
American Heart Association
www.americanheart.org
Heart Failure Society of America
www.hfsa.org
American Association of Heart Failure Nurses
www.aahfn.org
Intermountain Healthcare
www.intermountainhealthcare.com/heartfailure
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Thank You…
kismet.rasmusson@imail.org
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