MANAGEMENT STRATEGIES FOR HOSPITALIZED HF PATIENTS

It is well known that heart failure (HF) is a growing healthcare problem, associated with reduced quality of life, poor outcomes, and significant economic burden.1 A unified approach to cardiac risk factor identification and treatment is needed if we hope to abate this epidemic. The Joint Commission implemented a number of quality care performance indicators based on the Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease; among them are Core HF Measures for hospitalized HF patients. The goals of the Core HF Measures in acute decompensated heart failure (ADHF) are to improve utilization of existing HF therapies and discharge instructions in patients hospitalized with ADHF. Critical care nurses are in a unique position to improve the adherence and uptake of Core HF Measures for ADHF. Every patient encounter is an opportunity to educate a patient on cardiac risk factors and ensure that patients are being treated according to guideline recommendations, thus implementing Core HF Measures. The purpose of this article is to present a didactic discussion of HF management, which includes HF case studies and strategies for implementing Core HF Measures in the hospitalized HF patient.

DISEASE PREVALENCE AND HF POLICY

Heart failure remains a major public health problem associated with substantial morbidity and mortality, and a leading medical cause of hospitalization in persons over 65 years old.2 Despite advances in the diagnosis and medical management of heart disease, more than half a million new cases of HF are being diagnosed yearly.3 Once an HF diagnosis is established, patients are at risk for a host of HF-related syndromes and/or disease outcomes, of varying magnitude and presentation. These include, but are not limited to, pulmonary edema, hypertensive crisis, atrial fibrillation (AF) with rapid ventricular response (RVR), mitral regurgitation, and low-output syndromes, accompanied by hypotension and/or acute or chronic renal failure, contributing to the persistently high readmission rate of up to 50% within 6 months of discharge.4 The subsequent direct and indirect healthcare burden of treating HF is tremendous. In 2004, ADHF accounted for more than 1 million hospital discharges and 6.5 million inpatient hospital days, costing approximately $25.8 billion annually.5

Despite compelling evidence-based practice guidelines for HF management set forth by the American Heart Association (AHA), American College of Cardiology (ACC) Task Force, including recommendations for target doses of angiotensin-converting enzyme (ACE) inhibitors and treatment algorithms for [beta]-blockers, patients continue to be discharged home following an ADHF hospitalization on suboptimal treatments.6 The Acute Decompensated Heart Failure National Registry (ADHERE) tracks HF care practices and treatment patterns throughout the United States for hospitalized patients with ADHF.2 Data show that many of these patients are not receiving guideline-recommended diagnostic tests such as an echocardiogram (ECHO), patient education, discharge instructions, and/or HF medications and therapies.7 Low adherence to evidence-based practice guidelines and persistently high readmission rates for HF reinforces the need for effective strategies that will improve the utilization of existing HF therapies at hospital discharge.

The 2006 update to the AHA/ACC Guidelines for Secondary Prevention raises the prevention bar even higher, both challenging organizations and providing more stringent goals, which are directly attached to pay-for-performance reimbursement.8 Nurses are well suited to champion educational and performance improvement programs that can accomplish this level of performance. The implementation of Core HF Measures represents an opportunity for nurses to develop critical pathways that deliver HF-focused care, thereby reducing variability, improving guideline adherence and documentation, and ultimately improving the overall quality of care for ADHF patients.

Mr NewOnset CHF, age 74, presents to the emergency department complaining of progressive shortness of breath (SOB) and cough over the past 2 weeks. His symptoms intensified 5 days ago, and include dyspnea on exertion (DOE), orthopnea, decreased exercise tolerance, and increased lower-extremity edema. He reports being awakened many times per night over the past 5 nights with paroxysmal nocturnal dyspnea, limiting his ability to get restful sleep. He also describes the development of a cough productive of small amounts of thick white sputum. He denies febrile illnesses or other signs of infection, or sick contacts. He denies classic radiating chest pains, but does report some episodic chest pressure and gastric pain, brought on by lying flat and relieved by sitting up or taking antacids. In addition, he reports increasing anorexia, bloating, and transient nausea with medium- to large-sized meals; therefore, he has not been eating much over the past 5 days. Despite not eating much, he noted an increased weight gain of 13 lb. Medical history includes past tobacco use, lipid abnormality, and wide-angle glaucoma. His current medications include aspirin (ASA) daily, simvastatin at dinner, and prescription eye drops.

Physical assessment reveals a tired-appearing, breathless elderly male with a blood pressure (BP) of 102/54 mm Hg, a heart rate (HR) of 132 beats per minute, and a labored respiratory rate (RR) of 30 breaths per minute. Mr NewOnset CHF is diaphoretic, with jugular venous distention (JVD) to the angle of the jaw, a loud S3 gallop and 3/6 holosystolic murmur, loudest at the apex and radiating to axilla. He has bilateral, bibasilar, inspiratory crackles, and 3+ bilateral symmetrical pitting edema of the knees. His brain-type natriuretic peptide (BNP) level is greater than 1300, blood urea nitrogen (BUN) is 24, and serum creatinine level 1.4. Mr NewOnset CHF is admitted to your unit with a diagnosis of ADHF.

UNDERSTANDING THE BASICS

Over time, the paradigm for HF pathophysiology has shifted from a purely hemodynamic model to a neurohormonal model. We now understand that neurohormonal derangement promotes left-ventricular hypertrophy (LVH), an underlying culprit in HF. Neurohormonal disturbance and the progression of LVH are what guide the medical treatment plan. In HF, myocardial damage or dysfunction precipitates diminished cardiac output and is the stimulus for neurohormonal activation. Three of the major players (Table 1) are the renin-angiotensin-aldosterone system (RAAS), catecholamine release, and BNP level.10

Table 1. How RAAS activity, catecholamine release and BNP affect the cardiovascular system

Neurohormonal activation contributes to remodeling of the left ventricle (LV), characterized by LV dilatation, hypertrophy, fibrosis, and a more spherical, less functional LV chamber. Remodeling produces hemodynamic stress on the walls of the LV, thus reducing its mechanical performance. The neurohormonal responses to impaired cardiac performance, although initially adaptive, become counterproductive or deleterious over time.9 Continued progression results in impaired cardiac performance, leading to reduced blood flow to vital organs (ie, the kidney), thus contributing to decreased renal perfusion and chronic renal insufficiency.10 Activation of these vasoconstrictors adds to the hemodynamic burden on the failing heart, thus precipitating further deterioration of cardiac function, and chronic advanced HF ensues.9

When asked by a patient or family member to explain what happens to the heart in HF, first clarify the terminology. Explain that they may hear a number of different names given to the same condition, such as congestive heart failure (CHF), cardiomyopathy, or even diastolic heart failure. Defining HF presents a wonderful opportunity to educate patients, family members, and caretakers about the disease process. I explain that HF is a complex syndrome characterized by a cascade of events and symptoms in which the heart undergoes changes to its shape, structure, and function. This can occur in response to injury and/or increased demand or workload (hypertension and coronary heart disease). The process continues after symptoms decrease, or resolve, and HF becomes a lifelong condition that requires lifestyle changes, daily medications, monitoring, and close follow-up with a healthcare provider.

I use the analogy of a set of dominoes to explain the process of neurohormonal activation. I explain that the dominoes are placed upright next to one another in a row, and that an HF admission or hospitalization is similar to what happens on flicking the first domino. What follows is the cascade of events and HF symptoms. Like the dominoes, if the process is not halted, they keep tumbling until there are no dominoes left standing. The goals of HF treatments are to halt the cascade (progression of disease) of tumbling dominoes. If unchecked, terminal HF sets in, and with that comes some very unpleasant statistics, including an overall 5-year mortality rate of around 50%.5 Research has demonstrated that progressive LV remodeling relates directly to further decline in LV performance and increased mortality in HF patients.4

BASIC RECOMMENDATIONS FOR HF MEDICAL MANAGEMENT

What are the basic HF guidelines for the medical management of ADHF? Introducing HF medications is an example of a teachable moment for HF patients. I try to keep it simple, by explaining that ACE inhibitors are a family of medications used in HF that have been demonstrated to have life-prolonging effects by improving the structure and function of the heart. This is done by blunting the increase of heart size, which contributes to the heart's poor function or reduced ejection fraction (EF). Prescribe ACE inhibitors, or an angiotensin receptor antagonist (ARB), in all patients with current or prior symptoms of HF with an EF of 40 or less, unless contraindications due to hyperkalemia, angioedema, bilateral renal artery stenosis, or pregnancy.11 Initiate at low doses (eg, enalapril 10 mg twice daily) and titrate to target doses as tolerated by serum potassium, renal function, and blood pressure. Closely monitor serum potassium and renal function at 1- to 2-week intervals with chemistry panel. If ACE inhibitor is not tolerated or patient has adverse effects, ARB is recommended.11

[beta]-Blocker therapy is indicated for all classes of HF patients (low dose initially, with gradual titration) with asymptomatic LV dysfunction and/or LVEF of 40% or less.11 Contraindications are cardiogenic shock, severe reactive airway disease, and second- or third-degree heart block; however, to comply with guideline recommendations, contraindication should be documented, and patients should be given instructions and education regarding potential worsening of HF symptoms. Use of evidence-based [beta]-blockers for HF, such as carvedilol, metoprolol succinate, and bisoprolol, are recommended-with initiation at the lowest dose and titrate up to target dose at 2-week intervals and/or the highest tolerated dose depending on blood pressure and heart rate.9 Nurses need to clearly understand target heart rate, blood pressure response, and symptoms management such as dizziness, fatigue, or worsening HF, to assist patients in safely taking [beta]-blockers. Initiation of [beta]-blockers can start in the hospital setting with low doses and clear parameters to monitor the patient's response to the medication.12 As nurses we understand that a class of HF medications are used to block the effects of catecholamines, and a teachable point for patients is that this class of medications has been proven to decrease mortality and improve survival.9 An analogy I use in teaching patients about the use of [beta]-blockers in HF is to describe the effect of the medication as being similar to a governor on a car. It governs the heart's rate by not allowing it to elevate unregulated or race out of control. This process gives the heart more time to fill and squeeze more efficiently; therefore, it is important to call your provider before stopping the medication abruptly. I review the above-mentioned symptoms and provide instructions for expected treatment outcome and management.

Aldosterone antagonists (inhibitors) are indicated for all patients with Class II to Class IV HF with an EF of 40% or less. Contraindications are hyperkalemia and serum creatinine level greater than 2.5 in men or 2.0 in women.11 Use of evidence-based aldosterone antagonists for HF, such as spironolactone and eplerenone are recommended. Follow guideline dosing recommendations, monitor serum potassium level and renal function closely, and advance to target dose as tolerated.

What was Mr NewOnset's outcome? On admission, the HF cardiologist was notified, and Mr NewOnset was admitted to a progressive care unit, and placed on a continuous intravenous (IV) vasodilator. The vasodilators nesiritide (Natrecor) or nitroglycerin can be used along with IV diuretics. If nitroprusside (Nipride) is required as a vasodilator, the patient will require admission to an intensive care unit. A comprehensive cardiac workup was completed, including cardiac catheterization, which revealed 3-vessel coronary artery disease; ECHO revealed a dilated LV and EF of 23%. On hospital day 6, Mr NewOnset was discharged home. On examination, he had clear lungs, flat neck veins, no edema, normal sinus rhythm, a soft S3, near-normal renal function, and BNP 247. Mr NewOnset was diuresed 12 L and lost approximately 17 lb over the course of his hospital stay. His discharge medications included a small dose of diuretic, ACE, digoxin, simvastatin, and Aspirin (ASA). He was given a written discharge plan, including a medication list, scheduled follow-up in the HF clinic within 2 weeks, with recommendations for initiation of [beta]-blocker, once clinically stable.

Five years postincident HF admission, Mr NewOnset has stable ischemic cardiomyopathy, NYHA II, and a BNP of 123. He has not had any hospital admissions or emergency department visits for HF. His recent ECHO reveals a nondilated LV and EF of 58%. His medical regimen includes recommended doses of ACE, [beta]-blocker, aldosterone antagonist, simvastatin, ASA, a low dose of diuretic, and eye drops. Some of the rationale for successful response to therapy could be early implementation of guideline recommendations, including written discharge instructions; immediate enrollment into HF disease management program post-ADHF admission; aggressive risk factor management; supportive and actively involved family members; limited comorbid conditions (hyperlipidemia and glaucoma). Mr NewOnset required few lifestyle modifications. His tobacco use was in the past, not present, and he did not have alcohol or drug dependence. Therefore, patient education regarding medications, diet, and exercise were needed, and Mr NewOnset embraced self-management and complied with the recommended treatment plan.

LESSONS LEARNED AND INDICATIONS FOR CORE HF MEASURES

Lessons from chronic disease management models have taught us that bridging treatment gaps can be accomplished by implementation and monitoring of evidence-based performance measures.7 Mr NewOnset is an example of a good outcome when HF guidelines are put into practice. Evidence-based treatments initiated during an acute hospital admission have been shown to result in perceptions that the treatment introduced in the hospital setting is essential to survival and associated with long-term compliance.7 The Cardiac Hospital Atherosclerosis Management Program (CHAMP) demonstrated feasibility of standardized order sets, discharge checklist, focused algorithms, and data feedback through effective improvement in treatment rates, goal achievement, and clinical outcomes.13 Early third-quarter data from a hospital-based quality improvement program, "Get with the Guidelines," developed by the AHA demonstrated effective means of improving hospital care for acute coronary syndrome patients.14 The impact of guideline-based disease management programs on outcomes of hospitalized patients with HF provided evidence that an "active care management approach" was superior to "clinical practice guidelines alone" in improving quality and efficiency of care in ADHF patients.15

Despite the lessons learned from successful implementation of guideline-based treatment programs, and the evidence-based science behind the ACC/AHA HF guidelines and performance measures, nationwide tracking of HF events reveals high readmission rates, suboptimal compliance with recommended guidelines, and reported variability in HF outcomes. Thus the Joint Commission took a quantum leap toward aggressively improving HF care, mandating quality indicators geared toward improving hospital performance in the management of ADHF. These quality indicators defined and validated by the Joint Commission-better known as the Core HF Measures-consist of components of evidence-based guidelines embedded into discharge instructions that are endorsed by Medicare. They are adopted for improvement and accountability of HF care, as summarized in Table 2.16

Table 2. Summary of the Core HF Performance Measure

There is clear evidence to support that public reporting of performance and implementation of evidence-based guidelines leads to improvement in outcomes.7 Efforts to harmonize public reporting requirements that reduce burden while increasing the focus on improving HF care are the cornerstone for the Core HF Performance Measures.16 Hospitals and staff are getting with guidelines, because public reporting of these measures is mandated by the National Quality Initiative and linked to a pay-for-performance system, directly related to reimbursement for all HF discharges.16 Mandatory reporting has created a positive tension for improvement and accountability of HF care in the hospital setting. Successful implementation of the Core HF Measures highlights the critical component that nursing care offers to improve the quality care and outcomes for patients with ADHF.

Mr Chronic CHF, age 38, is an African American man who is being admitted to your unit today from the emergency department with worsening CHF symptoms. Mr Chronic CHF presented today complaining of dull chest ache, orthopnea, SOB, and decreased exercise tolerance. Mr Chronic CHF's history includes hypertension since his 20s; a schizoid-affective disorder for more than 10 years, which is stable; receives regular therapy for partial colectomy, carried out 10 years ago with staged colostomy and reanastomosis for diverticulitis; and idiopathic dilated cardiomyopathy (IDCM)/CHF, diagnosed 2 years ago, complicated by persistent resting sinus tachycardia for over 1 year. Other than long-standing untreated hypertension, his cardiovascular history is significant for idiopathic dilated CHF by ECHO with an EF of 42%, diastolic dysfunction, and pulmonary hypertension. His social history includes active heavy alcohol intake (6 beers daily) and positive tobacco history (smokes cigars). He underwent a comprehensive cardiac workup on his initial HF presentation 2 years ago, and a nuclear medicine study showed no evidence of ischemia (patient declined cardiac catheterization). Outpatient medications include psychiatric medications, ACE, and diuretic. Mr Chronic CHF confides that he noted a gradual decrease in his activity level and worsening DOE over the past month. His examination reveals a large, overweight man who is warm to touch and slightly diaphoretic, with BP 130 to 160 over 80 to 90 and HR 114, and JVD 10 cm; he has bibasilar crackles with a 3/6 holosystolic murmur of mitral regurgitation, positive S3 and S4 gallop, and 3+ pitting edema bilaterally. His chemistry, complete blood count, cardiac markers, and thyroid functions are unremarkable, with the exception of a BNP of 855. He is admitted to the progressive care unit, and treatment centers on reversing volume overload with IV diuretics and vasodilators. His hypertension and edema respond nicely to treatment, and he is transitioned to oral agents (ACE, diuretics, and psychiatric medications) and discharged home with the following instructions: cardiac diet, resume normal activity, daily weights, and call primary care provider if you experience increased weight, recurrent chest pain, or difficulty breathing. His discharge BP was 130/84, HR 101, and BNP 789.

PRIORITIZING NURSING CARE FOR ADHF PATIENTS-EARLY MANAGEMENT

Acute decompensated heart failure can be rapid or gradual in the onset of symptoms, but HF that necessitates hospitalization and/or augmentation of existing therapies, such as IV diuretics and vasodilators, are the high-risk ADHF population. Oftentimes, a hospital admission is preempted by augmented therapies such as IV diuretics and/or increased oral diuretics. It is important to get the story, the catalyst event or trigger. This information helps individualize patient education down the road regarding identification and prevention of future HF exacerbations.

Patients can present with or without congestion. Clinically, congestion presents with SOB at rest and/or with activity, diminished exercise tolerance secondary to SOB, orthopnea, paroxysmal nocturnal dyspnea, jugular venous distention, pulmonary crackles peripheral edema, ascites, and/or a third heart sound. Low perfusion states can manifest with cool extremities, changes in mental status, prerenal azotemia, oliguria, hypotension, narrow pulse pressure, pulsus alternans, and possibly low sodium levels. In an update on therapeutic options for HF management, Sorrentino provides a nice description of patient selection and treatment options.17 He reminds clinicians of the basic hemodynamic parameters present in ADHF, the presence (wet) or absence (dry) of elevated filling pressures, and adequate perfusion (warm) or diminished (cool) perfusion.3 For brevity, I am not going to review therapeutic options in ADHF, but refer you to the above-referenced article for a complete update, or Sheeba Varughese's article on management of ADHF in volume 30 of Critical Care Nursing Quarterly.17

The medical goals of early management are as follows: stabilize the patient hemodynamically and improve symptoms; manage blood pressure and heart rate; and reduce congestion and improve perfusion, without causing decreased coronary perfusion, and/or hypotension, ischemia, arrhythmias, or worsening renal dysfunction, to achieve the goal of euvolemia.18

An important aspect of the nursing care for these patients is obtaining a comprehensive needs assessment. Is this new-onset HF? If so, does the patient understand the disease process? What are the precipitants? What other risk factors or comorbid conditions does this patient have? What is the overall treatment plan? Does the patient have adequate social support? Where does the patient live, and who does he or she live with? How does he or she get around?

Is this chronic HF? If so, was there a precipitating event? What are the patient's risk factors, or other comorbid conditions? Is HF the only problem, or are there other issues? Does this patient understand the disease process? Is the HF management optimal? Who manages the HF? Where does he or she get his or her care? How about medications? Does he or she carry a medication list? Does he or she understand the medications? Does he or she have or has he or she experienced adverse effects from the medications? Can he or she afford the medications? What are his or her beliefs about the effectiveness of HF treatments? What is his or her attitude about the illness? Does he or she weigh himself or herself daily? If not, why? If so, what are the weights for the past week? Does he or she understand a low-sodium diet? Ask for a written 2-day recall of meals and snacks? Is it consistent with a low-sodium diet? Is there a knowledge deficit? Are there socioeconomic issues? Is he or she eligible for meals on wheels? Does your facility have an outpatient interactive home monitoring program, such as tele-health or tele-medicine? If so, is this patient enrolled? If not, is he or she a candidate? Does your facility have a disease management program for HF? If so, is this patient enrolled? If not, should he or she be? Are there any therapeutic options not explored, such as a biventricular pacemaker or implantable cardiac defibrillator? Is the medical team discussing this? Has this been discussed with the patient? What do they know and what have they heard or read about HF?

Is this advanced/refractory/end-stage HF? If so, who lives with and cares for this patient? Is the patient a cardiac transplant candidate? How about left-ventricular assist device? Does your facility have a transplant program, and is the HF team aware of this patient and/or discussing this option? Has social services been involved? What does the patient know about the severity of his or her illness? What are the goals of treatment for this patient? Have there been any end-of-life talks? If so, have goals of treatment and code status been clarified (full code/full care vs no code/comfort care)? Has a hospice referral or palliative care consult been placed? Is an advance directive in place and has it been updated?

Each of these categories carries unique education strategies as well as treatment algorithm. The nurse is in the perfect position to open discussions with patient and family, assessing their understanding of the illness and knowledge of the treatment plan, providing clarification and reassurance when needed regarding the purpose of procedures, medications, and treatment recommendations throughout the hospital admission, as well as discussing discharge plans and instructions.

DOOR TO FLOOR TO DISCHARGE HOME STRATEGY-IMPLEMENTING HF CORE MEASURES

In healthcare today, fast-tracking patients for early discharge is common practice, leaving little time for patient education. Moreover, implementing Core HF Measures throughout the busy hospital course is a challenge. Nonetheless, nurses are in a unique position to make patient education and HF nursing care a priority. It begins with educating the patients regarding the purpose of life-saving therapies, such as ACE inhibitors, [beta]-blockers, aldosterone-blocking agents, and preparation for recommended devices, such as biventricular pacemaker with implanted cardiac defibrillator. Once patients are informed, the introduction, initiation, titration, and/or optimization of HF treatments become less of a challenge. Often during this phase of the hospitalization, patient care gets lost in translation. They get caught between institutional goals for expedited discharges, the chaos of multiple providers, and transfer of care from primary teams (ie, HF specialists) to secondary teams (ie, electrophysiology team or general medicine team) followed by a sometimes abrupt discharge (need the bed for another patient) and a set of standardized HF discharge instructions, new prescriptions, and recommendations for several follow-up appointments, in a variety of different clinics.

Take the average 75-year-old patient with HF and other comorbid conditions, on multiple medications (many with associated adverse effects), more often than not leaving the hospital with worsening renal function, and preprinted discharge instructions to restrict fluid intake, change their diet, and/or other aspects of their lifestyle. We subject them to multiple healthcare providers and a host of follow-up tests, procedures, and instructions in a multitude of clinics. Now, ask yourself, why did the patient end up confused and poorly compliant (nonadherent) with the discharge treatment plan and/or recommendations?

These patients are high-risk, generally elderly, people with multiple comorbid conditions. Hospital-based HF-focused nursing care can minimize variations in the care being provided to these patients. Getting to the heart of Core HF Measures and successfully addressing individual patient-education priorities (while keeping providers on task to enhance documentation) is a challenge, but teaching patients and providing holistic care are the backbone of nursing. Making HF nursing care a priority can markedly improve not only the process of hospitalized HF management but the overall quality of HF care. The reason hospital-based, patient-centered HF programs work for HF management is illustrated in Table 3.

Table 3. Why hospital-based HF nursing education programs work for HF management?

Acute decompensated heart failure is a deadly, debilitating, and costly syndrome that has a significant impact on the healthcare system, patients, and families. Developing new approaches to improving hospital-based HF nursing education programs will curtail the unacceptably high morbidity, mortality, and healthcare expenditure for readmission in ADHF.

Let us take another look at Mr Chronic CHF 2 years later, as he is being admitted from his primary care physician's office to your unit for low systolic BP (88), tachycardia, and worsening CHF symptoms. Today he presented complaining of notable fatigue, persistent SOB, and malaise. His history is unchanged, with the exception of worsening LV function by a recent ECHO taken 6 months ago, with an EF of 31%, and documented intolerance to ACE secondary to worsening renal function and hyperkalemia. There is a brief mention of [beta]-blocker initiation over the past year, but no clear documentation of contraindication. He complains of nonproductive cough and worsening lower-extremity edema. He denies chest pain, sick contacts, recent travel, or urinary symptoms. He is aware of the increased swelling in his legs, but cannot tell you if he has gained weight because he does not weigh himself daily. He reports taking all of his medications regularly, but cannot tell you what they are. His current medications include (per computerized health record): hydralazine 3 times daily, isosorbide at bedtime, low-dose ASA, high-dose diuretic, and aldactone. His blood work reveals worsening renal function and a BNP level of 3320.

When you review the medical records from a previous admission a month ago, you find that Mr Chronic was admitted from another clinic appointment for decompensated CHF complicated by new-onset rapid atrial flutter, which was cardioverted after transesophageal echo. At that time, EF was estimated to be 11%, and a new outpatient ECHO was ordered but not scheduled. Mr Chronic, now Advanced-End-Stage CHF, received aggressive diuresis with a negative 3.8 L achieved. Of note, his blood pressure was consistently low, with systolic blood pressure (SBP) in the 85 to 90 range, although asymptomatic. Orthostatic measurements were negative. During hospitalization, he was transitioned to oral diuretics and low-dose enalapril, with stable renal function observed afterwards. [beta]-Blocker was not started owing to hypotension. The plan was to initiate as an outpatient. Mr Chronic-Now-End-Stage CHF remained in normal sinus rhythm at discharge.

Today's physical assessment reveals a tired-appearing, breathless man with a BP of 88/54, an HR of 122 beats per minute, an RR of 30, and an approximate 30-lb weight gain. His skin is cool to touch and he is diaphoretic, with JVD to the angle of the jaw, a loud S3 gallop, and a 3/6 holosystolic murmur, loudest at the apex. He has bilateral bibasilar inspiratory crackles, and 3+ bilateral symmetrical pitting edema to the knees. Mr Chronic-Now-End-Stage CHF is admitted to your intensive care unit, with a diagnosis of ADHF. The "cold-wet" patient is the sickest HF patient, with the highest inpatient mortality rate.10 These patients have severe impairment of cardiac function associated with disabling symptoms (marked dyspnea, fatigue) at rest, and reduced functional capacity (end-organ hypoperfusion). They require frequent outpatient visits, recurrent hospitalizations, and have high mortality rates. The focus of treatment for this class of patients is geared at improving perfusion and, thus, necessitates clarifying goals of treatment (cardiac transplant, left-ventricular assist device, and/or hospice). The case of Mr Chronic-Now-End-Stage CHF confirms the importance of early implementation of evidence-based guideline in aggressive, comprehensive HF management geared toward improving quality of life and chances of survival.

ACCEPTING THE CHALLENGE AND CHANGING THE CULTURE OF HF NURSING EDUCATION

The VA San Diego Healthcare System (VASDHS) is an illustration of moving guidelines from paper to practice, prioritizing quality care by building an infrastructure to serve as the foundation for successful performance improvement. In 2003, the VA Blue Ribbon Panel outlined a National VA policy to Improve Cardiac Care through participation in publicly shared performance initiatives. The VASDHS developed a local multidisciplinary task force of hospital-based clinicians composed of an HF cardiologist, nurse practitioner, nurse case manager, dietitian, pharmacist, nursing information technologist, and a nurse expert in performance improvement programs. This team was charged with implementation of the acute coronary syndrome and the Core HF Measures.

The group reviewed the ACC/AHA Task Force Practice Guidelines, the VA External Peer Review Program, and the JCAHO Core HF Measures/performance guidelines.19 They developed and implemented computerized, user-friendly critical pathways that guide healthcare providers through accepted treatment regimens, guidelines, and algorithms while assisting with documentation and compliance data collection. The treatment pathways and algorithms are indicated for use from door to discharge, and include diagnosis-specific discharge instructions.19 Effective implementation of order sets and adoption of algorithms into practice is vital to effectively changing the culture of HF management and patient outcomes-particularly for nurses, who are responsible for patient and staff education.

The Core HF Measures focus on patient education and behavior changes needed to improve survival and quality of life. These Core HF Measures are embedded in all HF discharge instructions and include daily weights, activity level, diet and fluid intake instructions, written medication list, written instructions for what to do if symptoms worsen, and smoking cessation counseling. To succeed in implementing the Core HF Measures, the task force solicited the help of Nursing Service, partnering with an existing Nursing Service Performance Improvement (PI) Council, chaired by a clinical nurse specialist. The team's scope broadened to that of change agent as it partnered with the clinical nurse specialist, a systems expert, and chair of the PI Council. The Nursing PI Council utilized RN facilitators from patient care areas and clinics throughout the system, thus providing links to all patient care areas and every nurse.

The AACN Synergy Model for Patient Care formed the backdrop for changing practice at the VASDHS.20 Bringing HF nursing care to the forefront, as a goal for safe passage of the HF patient, from door to floor and home, is the key to integrating guidelines into practice. The core premise of the Synergy Model is that the needs of patients and families drive the competencies of the nurse. The abundance of evidence-based guidelines for HF gives this vulnerable and complex population a degree of predictability. Using the synergy model, the PI leadership team identified 3 nursing service competencies necessary to meet the needs of the HF patient: clinical judgment, facilitation of learning, and collaboration.21,22

The Core HF Measures were used to create core competencies for nursing service to enhance clinical judgment. The Task Force and PI Council provide ongoing staff education and in-service training, teaching core HF curriculum and management strategies with resources such as PowerPoint presentations, pocket cards, and posters. The PI nurses disseminate guidelines and coordinate in-service presentations for all of their respective units and staff.

A case study approach is useful in demonstrating the nurses' role in achieving quality outcomes, illustrating good HF case management, as well as highlighting cases showing discrepancies in HF management and resulting outcomes. An example of a good case study would be Mr Chronic. A question to evaluate current knowledge and guide learning would be, "How would you prioritize nursing care for Mr Chronic?" I would tease out a few issues in Mr Chronic's case, issues that could be posed as questions for learning purposes: underlying psychiatric condition (knowledge deficit vs cognitive impairment); medication noncompliance versus undertreatment versus inadequate HF management; presence of persistent tachycardia of greater than 1 year; and another keen discussion point could be the significance of a lack of change in Mr Chronic's BNP level during his admission (on one occasion it was 855) and that on discharge (BNP 789).

A side note to highlight the importance of nurse-led interventions in HF management10: Mr Chronic-Now-End-Stage was referred to an HF disease management team following his last ADHF admission. He continues to be followed in a nurse practitioner HF clinic biweekly (now moving to every 3 weeks), and is enrolled in a tele-health monitoring program with nurse case management and home health nursing follow-up for medication management. He has not been admitted to the hospital in 5 months. He has a BP of 114/70, an HR of 74, no edema, a positive S3, and neck veins are flat. He can walk 6 to 8 blocks to the bus slowly. His BNP is 176 and he is on a recommended dose of [beta]-blocker, small dose of ACE, and small doses of diuretic and coumadin. Mr Chronic-Now-End-Stage is an excellent case study of putting guidelines into practice; however, Mr NewOnset is a better example of why it is important to implement guidelines early.

As the nurses' comfort levels improve with the Core HF Measures, they will embrace focused HF nursing care, as an important contribution to successful achievement of HF management, and their collaborative practices will increase.23 As hospital-based nurses become comfortable and integrate the Core HF Measures into their daily practices, patient care for patients with ADHF will improve.

The HF task force tracks adherence to Core HF performance measures and reports performance outcomes quarterly to the PI Council. One of the performance measures focused on over the past quarter is written discharge instructions regarding daily weights. A goal of the HF task force and PI Council nursing leadership is 100% compliance on all HF discharge instructions and improved performance on the status quo of the HF discharge instructions. This will require nursing PI projects to implement patient educational materials and develop new strategies with nurse teaching points included. Providing staff nurses skills to effectively facilitate patient education empowers patients and staff to move the HF process in the direction of self-management.22 The process of focused HF care and patient education sets the stage for an attitudinal shift within nursing service, from that of documentation compliance to effective assessment and successful patient learning. All along the critical pathway from door, to floor, to discharge, nurses play an integral role in the continuum of care for HF patients.

SUMMARY/WORTH THE EFFORT

Teamwork through nursing intervention and performance improvement can reduce the variability in care delivered to hospital-based HF patients. There are numerous opportunities for nurses to get involved with performance improvement (PI) projects and significantly change outcomes for HF patients. A few creative ideas for nursing PI projects that could change the status quo of HF discharge instructions are highlighted in Table 4.

Table 4. Nursing performance improvement projects for implementing heart failure discharge instructions

Because HF cannot be "cured" with medications, devices, and/or therapies, patients require lifelong HF management and patient education that promotes adherence with HF treatments.10 The HF task force and nurse PI council implemented a 4-zone HF symptom management guide at discharge. This colorful 1-page HF stoplight guide provides a refrigerator-ready handout to symptom change. The Green Zone indicates all clear, where symptoms are unchanged. Yellow Zone is caution, where signs and symptoms of HF are increasing. Orange Zone alerts the patient to the need for medical attention. The final Zone is Red and instructs the patient or caregiver to seek immediate attention and call 9-1-1. This teaching aid has medical contact information with instructions for whom to call with each zone.

Focused HF Nursing care (such as the above-mentioned HF stoplight) can reduce problems of variability in healthcare delivery, thus improving the quality of care, enhancing documentation and guideline adherence, and educating, thereby empowering patients toward self-management of their chronic illness.10 To succeed, nurses need to be actively engaged in the patient learning process. Educational needs for HF management should focus not only on the patient but also on the staff.

Further nursing research is needed to identify priorities that will successfully address the needs of HF patients. We need to provide evidence for effective nurse-led interventions and develop strategies for behavioral management, self-care, and education that encourages HF patients' active involvement in their own care.1 The adoption of hospital-based initiation of evidence-based HF guidelines and Core HF Measures as a standard of care has the potential to improve treatment rates and patient outcomes, and reduce hospital readmissions in ADHF patients.7 Nurses are in an excellent position to use their expertise in teaching patients and serving as patient advocates, while championing the uptake and adherence of Core HF Measures, thus improving the quality of patient care in ADHF. Remember, guidelines that aren't implemented won't work!!

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