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10/30/2013 1 ©Pathway Health 2013 To Transfer or Not To Transfer: That Is the Question LeadingAge New York – The Sagamore Resort DNS/DSW Annual Conferences November 14, 2013 Louann A. Lawson, BA, RN, RACCT Nurse Consultant/Clinical Reimbursement Team Leader [email protected] ©Pathway Health 2013 Highlight key factors related to acute care transfers Discuss ways the Affordable Care Act addresses hospital re-admissions Identify the key clinical competencies related to management of CHF, Pneumonia, Acute MIs, UTIs, and Sepsis as well as those associated with advance care planning discussions Identify ways to incorporate INTERACT Version 3.0 into your organization’s quality improvement efforts Objectives 2 ©Pathway Health 2013 25% of Medicare patients admitted to SNFs from hospitals are readmitted to a hospital within 30 days Some Facts 3 ©Pathway Health 2013 Up to 67% of hospital transfers are rated as potentially avoidable by expert LTC professionals Some Facts 4 ©Pathway Health 2013 Medicare has financial incentives in place to reduce potentially avoidable hospital transfers through pay-for-performance, bundled payments, and other strategies Some Facts 5 ©Pathway Health 2013 The Patient Protection and Affordable Care Act is focused on a triple aim: Improving quality of care Improving health Making care affordable Health Care Reform 6

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Page 1: LeadingAge NY Transfers Submitted › home › assets › File › Lawson_To Transfer...Adult Learning Cycle ©Pathway Health2013 • “The Basics” – Hand Washing, Vital Signs,

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1

©Pathway Health 2013

To Transfer or Not To Transfer:

That Is the Question

LeadingAge New York – The Sagamore Resort DNS/DSW Annual Conferences

November 14, 2013Louann A. Lawson, BA, RN, RAC‐CT

Nurse Consultant/Clinical Reimbursement Team [email protected]

©Pathway Health 2013

• Highlight key factors related to acute care transfers

• Discuss ways the Affordable Care Act addresses hospital re-admissions

• Identify the key clinical competencies related to management of CHF, Pneumonia, Acute MIs, UTIs, and Sepsis as well as those associated with advance care planning discussions

• Identify ways to incorporate INTERACT Version 3.0 into your organization’s quality improvement efforts

Objectives

2

©Pathway Health 2013

25% of Medicare patients admitted to SNFs from hospitals are readmitted to a hospital within 30

days

Some Facts

3©Pathway Health 2013

Up to 67% of hospital transfers are rated as potentially avoidable by expert LTC professionals

Some Facts

4

©Pathway Health 2013

Medicare has financial incentives in place to reduce potentially avoidable hospital transfers through

pay-for-performance, bundled payments, and other strategies

Some Facts

5©Pathway Health 2013

The Patient Protection and Affordable Care Act is focused on a triple aim:

• Improving quality of care• Improving health• Making care affordable

Health Care Reform

6

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©Pathway Health 2013

Hospital Readmission Reduction Program

• Began October 1, 2012• Medicare recovers payments from hospitals for

unnecessary re-admissions within 30 days of discharge.

• Pneumonia, CHF, and Acute MI were the first diagnoses to be monitored

• Recovery amounts will increase, the number of diagnoses being monitored will increase, and there may be recovery of payments from other providers.

HRRP – Part of ACA

7©Pathway Health 2013

• Set up a systematic, self-sustaining process

• Anticipate, Prevent, Intervene Early

• Improve and Celebrate

Once the situation deteriorates, it’s very difficult to prevent a transfer

Key Points: Day-to-Day

8

©Pathway Health 2013

A Quality Improvement Program

9©Pathway Health 2013

• The INTERACT Version 3.0 tools are meant to be used together in your daily work in the nursing home

http://interact2.net

Quality Improvement & INTERACT

10

©Pathway Health 2013

• Preventing conditions from becoming severe enough to require hospitalization through early identification & assessment of changes in resident condition

• Managing some conditions in the NH without transfer when this is feasible and safe

• Improving advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization for some persons

Safe Reduction of Hospital Transfers

11©Pathway Health 2013

• Sadie• Sara• Sam

A Tale of Three Siblings

12

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©Pathway Health 2013

96-year-old Long-Stay NH Resident• Hospitalized for UTI and dehydration• Discharged back to the NH after 4 days• Re-hospitalized 7 days later for

dehydration and recurrent UTI

Preventable?

Sadie

13©Pathway Health 2013

INTERACT Strategy

14

Prevent conditions from becoming severe enough to require hospitalization through early detection and evaluation

©Pathway Health 2013

98-year-old Long-Stay NH Resident • Hospitalized for a lower respiratory

infection, but had normal vital signs and oxygen saturation

• Developed delirium in the hospital, fell, fractured her pubis, and developed a pressure ulcer

Preventable?

Sara

15©Pathway Health 2013

Manage some conditions in the NHwithout transfer when it is feasible and safe

INTERACT Strategy

16

©Pathway Health 2013

101-year-old Long-Stay NH Resident• Hospitalized for the 4th time in 2 months

for aspiration pneumonia related to end-stage Alzheimer’s disease

• Transferred to hospice on the day of re-admission

Preventable?

Sam

17©Pathway Health 2013

INTERACT Strategy

18

Improve advance care planning and the use of palliative care plans when appropriate as an alternative to hospitalization

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©Pathway Health 2013

• Delay in identifying change in condition

• Lack of evaluation before calling physician

• Physician insistence on transfer

• Resident or family expectations

• Communication problems between nurses, or between nurses & primary care clinicians

• Services needed are not available or timely in the facility

• Delay in advance care planning

• Others?

Common Trends

19©Pathway Health 2013

Stop and Watch

20

©Pathway Health 2013

• Seems different than usual

• Talks or communicates less

• Overall needs more help

• Pain – new or worsening; Participated less in activities

STOP

21©Pathway Health 2013

• Ate less

• No bowel movement in 3 days; or diarrhea

• Drank less

and

22

©Pathway Health 2013

• Weight change

• Agitated or nervous more than usual

• Tired, weak, confused, or drowsy

• Change in skin color or condition

• Help with walking, transferring, toileting more than usual

WATCH

23©Pathway Health 2013

• To guide direct care staff

through a brief review of

early changes in a resident’s

condition

• To improve communication

between frontline staff and

the nurse in charge about

early changes in condition

Begins the assessment process

Shortens response time

Clinical care to reduce avoidable hospital 

transfers begins with this tool

STOP and WATCH Purpose

24

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• Addresses relevant changes in condition

• Actions and behaviors that are not part of the resident’s normal routine

• A change from the resident’s baseline

• Consistent assignment is a key concept for effect use

INTERACT Early Warning Tool

25©Pathway Health 2013

• Change in Condition File Cards

• Care Paths

Decision Support Tools

26

©Pathway Health 2013

• The INTERACT Change in Condition File Cards are meant to be visible and to sit next to the phone for quick reference.

• New version based on AMDA Clinical Practice Guidelines

Change in Condition File CardsINTERACT Decision Support Tools

27©Pathway Health 2013

• When to Report to MD/NP/PA– Immediate vs. Non-Immediate

• Vital Signs– B/P, Pulse, Respirations, Temperature– Weight loss or gain

• Lab Tests & Diagnostic Procedures– CBC, Chemistry, Consults, INR, Urinalysis, Urine

Culture, X-Ray

• Signs & Symptoms A - Z

Change in Condition File Cards

28

©Pathway Health 2013

Care Paths

29©Pathway Health 2013

• Acute Mental Status Change• Change in Behavior: New or Worsening

Behavioral Symptoms• Dehydration• Fever• GI Symptoms – Nausea, Vomiting, Diarrhea• Shortness of Breath• Symptoms of CHF• Symptoms of Lower Respiratory Illness• Symptoms of UTI

Expanded List of Care Paths

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©Pathway Health 2013

• Rose has a history of COPD and CAD and had an acute MI 6 months ago

• At 8 P.M. she complains of increased shortness of breath after an upsetting phone call with her daughter

• Her respiratory rate is 26, her oxygen saturation is 92%, both unchanged from her baseline

• The nurse finds no abnormal lung sounds on exam

• Does the clinician on call need to be notified immediately?

Case Study: Rose, 92, LT NH Resident

31©Pathway Health 2013

• Two days later, the nurse notes that Rose’s breathing is a little more labored

• Her respiratory rate is 30 and her oxygen saturation is 89%. She has faint wheezes on lung exam.

• She also has the new onset of pedal edema

• Does the clinician on call need to be notified immediately?

Case Study: Rose, 92, LT NH Resident

32

©Pathway Health 2013

Change in Condition File Cards

33©Pathway Health 2013

• Immediate– Abrupt onset of s.o.b. with pain fever, or

respiratory distress

• Non-Immediate– Recently progressive or persistent minor

s.o.b. without other symptoms OR with progressive leg edema

Shortness of Breath

34

©Pathway Health 2013

Refer also to the CHF and Lower Respiratory Infection Care Paths

Care PathsINTERACT Decision Support Tools

35©Pathway Health 2013

Increase Nursing Staff Competency

Critical Component of Strategic Plan

36

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©Pathway Health 2013

Where Do We Begin?

37©Pathway Health 2013

Know Where Your Participants Stand

• Why are they there?

• What do they believe?

• What do they know?

Education Plan

38

©Pathway Health 2013

3 Domains of Learning

• Knowledge– Evidence-based

• Attitudes– Core beliefs

• Skills– Tools, Resources, Implementation strategy

Education Plan

39©Pathway Health 2013

Experience –Past & Present

Reflection

Generalization

Application

40

Adult Learning Cycle

©Pathway Health 2013

• “The Basics”– Hand Washing, Vital Signs, Weights

• Specific Disease States– Pneumonia, CHF, AMI, UTI, Sepsis

• Change in Condition (SBAR)– Mental status, Functional status, Respiratory, GI/Abdomen,

GU/Urine Changes

• Professional Communication– Internal and External

• Advance Care Planning

Suggested Competencies

41

©Pathway Health 2013

The Department of Veterans Affairs National Center for Patient Safety Hierarchy of Actions

42

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The weakest link in the process is implementing solutions that are centered on

training & education, or asking clinicians to “be more careful.”

The Weakest Link

43©Pathway Health 2013

Weak actions enhance or enforce existing processes:

• Double checks • Warnings/labels • New policies / procedures / memoranda • Training/education

Depend on staff to remember their training or what is written in the policy.

WEAK Actions

44

©Pathway Health 2013

These solutions don’t impact the system, & are based on two assumptions-

1. Lack of knowledge contributed to the event,

and

2. If a person is educated or trained, the mistake won’t happen again.

WHY?

45©Pathway Health 2013

Solutions that rely on vigilance or memory are equally problematic because they create expectations for staff to remember more or be more careful.

This is not always realistic when staff are in stressful situations or when multi-tasking.

If the system doesn’t provide support, it is part of the problem.

Human Error

46

©Pathway Health 2013

Somewhat dependent on staff remembering to do the right thing, but provide tools to help staff remember or to promote clear communication.

Intermediate actions modify existing processes:

• Decrease workload • Software enhancements & modifications • Checklists, cognitive aids, triggers, prompts • Read back • Enhanced documentation & communication

INTERMEDIATE Actions

47©Pathway Health 2013

Do not depend on staff to remember to do the right thing.

May not totally eliminate the vulnerability but provide strong controls.

Change or re-design the process - help detect & warn so there is an opportunity to correct before the error reaches the patient.

STRONG Actions

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©Pathway Health 2013

Won’t allow the process to continue unless something is corrected or signals intervention to prevent significant harm:

• Physical changes: grab bars, nonslip strips

• Forcing functions: only O2 can be run to oxygen lines

• EMR: cannot save unless all fields are filled in

• Simplifying: unit dose

Strong Actions = Hard Stops

49©Pathway Health 2013

• There will be an investment of time.

• Involve staff at all levels in change process

• Be transparent: share goals, timeline, all data, and results (good and bad) with staff frequently as change is implemented across facility

• Ask for and listen to staff input throughout implementation process

Leadership Buy-In

50

©Pathway Health 2013

Specific Disease States

51

©Pathway Health 2013

Pneumonia

52

©Pathway Health 2013

Lower respiratory tract infection is one of the leading causes of preventable hospital readmissions.

• Pneumonia is the 6th leading cause of death in the United States.

• CDC recommends high risk groups get vaccinated against the flu and bacterial pneumonia

Pneumonia & the ACA

53©Pathway Health 2013

• Mortality rate 30-50%

• Risk factors: – Emphysema– Chronic bronchitis – Diabetes

• Most pneumonias are due to aspiration (CDC)

Pneumonia

54

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• Pneumonia is an inflammation of the lungs caused by infection.

• Battling the infection, the alveoli (air sacs in the lungs) fill up with mucus, pus, white blood cells, and other liquids.

• Makes it difficult for oxygen to reach the bloodstream. Causes risk for infection to spread to the entire body.

Pneumonia

55©Pathway Health 2013

• Pneumonia can range in seriousness from mild to life-threatening.

• Pneumonia often is a complication of another condition, such as the flu.

• Antibiotics can treat most common forms of bacterial pneumonias, but antibiotic-resistant strains are a growing problem.

• The best approach is to try to prevent infection.

Pneumonia

56

©Pathway Health 2013

• Collapse of lower airways

• Weakened chest muscles

• Decreased swallowing ability

• Decreased elastic tissue surrounding alveoli

• ↑ Fibrous connective tissue of rib cage: ↓ bronchial movement, ↓air exchange, ↑residual air

• At end of expiration, 80 year old has 50% more air left in lungs than 25 year old

Pneumonia

57©Pathway Health 2013

• Noninfectious cardiac and pulmonary disorders, such as CHF.

• Asymptomatic acute myocardial infarction—fever, shortness of breath, and chest pain—may mimic pneumonia – ECG & cardiac enzyme levels help rule out MI

• Pulmonary embolism– Arterial blood gas analysis or lung scanning may

rule out pulmonary emboli as a cause of the patient's pulmonary symptoms.

Rule Out Other Conditions

58

©Pathway Health 2013

• Must have CXR demonstrating pneumonia or a new infiltrate

• AND• One of following:

– New or increased cough– Pleuritic chest pain– New or increased sputum production– O2 Sat < 94% RA or reduction of >3% baseline– New or changed abnormal chest exam(Lung

sounds)– Respiratory rate ≥ 25

New McGeer Criteria (1 of 2)

59©Pathway Health 2013

• AND• Must have at least one of the

Constitutional Criteria– Fever– Leucocytosis– Acute change in mental status from baseline– Acute functional decline

• Bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, eating

New McGeer Criteria (2 of 2)

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©Pathway Health 2013

• Symptoms may be masked due to co-existing disease states, corticosteroids, and anti-inflammatory medications

• May first present with failure to thrive, increased rate of respirations, altered mental status, dehydration

• Chest x−rays, complete blood count, and pulse oximetry are basic diagnostic tools.

*First symptom of weakness may be a fall

Presenting Symptoms

61©Pathway Health 2013

• Pain is usually sharp and worsens when taking a deep breath and is known as pleurisy pain

• In other cases of pneumonia, depending on the causative organism, there can be a slow onset of symptoms.

• A worsening cough, headaches, and muscle aches may be the only symptoms.

• Productive cough– Noisy, expulsive, forceful and involves blood, sputum – Observe for color, odor, consistency of sputum– Note frequency and intensity

Symptom Progression

62

©Pathway Health 2013

• Bacteremia– Bacteria in the bloodstream

• Lung abscess– A cavity containing pus (abscess) that forms within the

area affected by pneumonia is another potential complication

• Acute respiratory distress syndrome (ARDS)– The pneumonia involves most areas of both lungs,

making breathing difficult and depriving their body of oxygen. Underlying lung disease of any kind, but especially COPD, increases susceptibility to ARDS.

• Pleural effusion– Fluid collects in the pleural space around the lung as a

result of the inflammation from pneumonia

Pneumonia Complications

63©Pathway Health 2013

• Right-sided lying – Infiltrates most likely involve the

right upper lobe.

• Left-sided lying – Most likely location of the infiltrates is the left

upper lobe.

• Supine– Multiple lobes involved

Cunha, B.,MD, Bronze, M., MD, (2012)

Position Matters

64

©Pathway Health 2013

• Inflammation of the lungs and airways to the bronchial tubes from breathing in foreign material.

• Aspiration pneumonia occurs when foreign materials (usually food, liquids, vomit, or fluids from the mouth) are breathed into the lungs or airways leading to the lungs.

Aspiration Pneumonia

65©Pathway Health 2013

• Past episodes of aspiration, aspiration pneumonia

• Cerebral palsy, muscular dystrophy, epilepsy, GERD, dysphagia or hiatal hernia

• Inappropriate food textures or fluid consistency

• Drowsiness, lethargy (may be medication-related)

• Unable to sit upright while eating

Aspiration Alerts

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• Rhinitis while eating

• Persistent coughing during or after meals

• Irregular breathing, turning blue, moist respirations, wheezing or rapid respirations, chronic asthma, congestion

• Food or fluid falling from mouth or drooling

• Intermittent fevers

• Chronic dehydration

• Unexplained weight loss

• Vomiting, regurgitation, rumination and/or odor of vomit or formula after meals

Aspiration Warning Signs

67©Pathway Health 2013

• Yale Study linked oral care and respiratory illness

• The Dental Health Foundation has warned that poor oral hygiene could cause respiratory infection after research found a link between bacteria in the mouth and the lung disease

• Study states more research is needed to know exact link between the two.

Pneumonia & Oral Hygiene

68

©Pathway Health 2013

• Viral infections• COPD, emphysema• Heart disease• Diabetes• Alcoholism

• Drug addiction• Stroke• Seizure• Poor oral health• Feeding Tubes• Smoking• Pain

Admission Risk Factors

69©Pathway Health 2013

• When measuring and recording respirations the rate, depth and pattern of breathing should be recorded for a full minute

• A respiratory rate of 12-18 breaths per minute in a healthy adult is considered as normal (Blows, 2001)

• Tachypnea the rate is regular but over 20 breaths per minute

• Bradypnea - the rate is regular but less than 12 breaths per minute.

• Apnea - there is an absence of respiration for several seconds this can lead to respiratory arrest.

Respiratory Assessment

70

©Pathway Health 2013

• Dyspnea - difficulty in breathing, the patient gasps for air.

• Cheyene-Stokes Respiration -breathing is shallow, very slow and labored with periods of apnea. This type of breathing is often seen in the dying patient.

Respiratory Assessment

71©Pathway Health 2013

• Observe the breathing – Is the person mouth breathing, pursing the lips

on expiration, using the abdominal muscles or flaring the nostrils?

Respiratory Assessment

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• Note the color of the person's lips

• They may be cyanotic (blue) or discolored if the patient has respiratory problems

• Cyanosis can also be observed in the nail bed, tip of the nose and ear lobes

(Woodrow, 2005)

Respiratory Assessment

73©Pathway Health 2013

Oxygen Saturation

• The oxygen saturation (SaO2) may be recorded using a pulse oximeter.

• This will provide an accurate reading of oxygenation in the red blood cells.

• With pneumonia, often the O2 sat is < 94%

(McGeer, 2012)

Respiratory Assessment

74

©Pathway Health 2013

Oxygen

• If a patient has been prescribed oxygen, ensure the oxygen mask or nasal cannula is correctly placed prior to recording respirations

• Check that the oxygen flow rate is set as prescribed and recorded

• Observe if resident compliant with use of NC or mask

Respiratory Assessment

75©Pathway Health 2013

Lung Sounds

• Clean stethoscope• Correct placement of stethoscope• Have return demonstration• Use youtube.com for educational

resources• Frequent checks if abnormal lung sounds

are heard. (Not just on admission)

Respiratory Assessment

76

©Pathway Health 2013

• Coarse or crackling sounds, wheezing, or faint breathing sounds

• Chest x-ray reveals congestion and fluid, inflammation

• Sputum contains organisms

• WBCs – ↑ neutrophils are seen in bacterial infections, – ↑ lymphocytes are seen in viral infections, fungal

infections, & some bacterial infections (like tuberculosis).

• Bronchoscopy-examination & specimens from infected area.

Pneumonia Diagnosis

77©Pathway Health 2013

Focus on Prevention

78

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• Good hand washing!– Audit, Audit, Audit!

• Review respiratory assessments• Treat pain (Review therapy schedules)• Have pillows for repositioning• Hug pillow for pain• Use of incentive spirometer• Encourage turning, coughing and deep breathing• Immunization!

Interventions for Prevention

79©Pathway Health 2013

Standard aspiration precautions

– Administer tube feedings in an upright sitting position

– Keep HOB elevated at least 45 degrees or per orders

– Check for placement & residual with each infusion

– Don’t feed too rapidly

– Administer meds one at a time to gravity

– Feedings should be administered over at least 30

minutes or as ordered

Prevention - Enteral Feedings

80

©Pathway Health 2013

• Ensure caregivers are following precautions for assisting with eating/drinking

• Report weak or absent coughing/gagging reflexes, changes in chewing or swallowing skills

• Report food stuffing, rapid eating/drinking, pocketing or pooling of food

Interventions for Prevention

81©Pathway Health 2013

• Involve speech therapy

• Audit for proper technique for enteral feedings

• Audit direct care staff with ADLs (HOB up)

• Review who is feeding those at risk

• Staff access to feeding techniques from ST

Interventions for Prevention

82

©Pathway Health 2013

• Teach good oral care

• Audit that it is being performed- return demonstration

• Change toothbrush after any type of illness

• Routine dental care by dental hygienist or dentist

• Good hydration

Prevention – Oral Hygiene

83©Pathway Health 2013

• Hand hygiene after contact with respiratory secretions

• Wearing gloves for suctioning

• Elevating the head of the bed 30 to 45 degrees during tube feeding and for at least 1 hour after to decrease aspiration

• Vaccination of high-risk residents with pneumococcal vaccine.

CDC Recommendations

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• The pneumococcal vaccine protects against multiple bacteria species, the most common cause of respiratory infections.

• Experts now recommend that more people, including healthy elderly people, be given the pneumococcal vaccine, particularly in light of the increase in antibiotic-resistant bacteria.

Pneumococcal Vaccine

85©Pathway Health 2013

Oxygen Administration

• Humidity– Sterile water (not distilled or tap)

• Humidifier– Clean according to manufacturer– Sterile

CDC Recommendations

86

©Pathway Health 2013

Understanding and Management of Heart Failure

CHF

87©Pathway Health 2013

• Primarily a condition of the elderly

• Incidence of Heart Failure is 1 per 100 population after age 65

(2009 Update to American Heart Association 2005 Guidelines)

• The most common Medicare hospital discharge diagnosis

• More Medicare dollars being spent on this diagnosis than on any other single diagnosis

CHF & ACA

88

©Pathway Health 2013

• May be referred to by several names:

– Heart Failure– Congestive Heart Failure– Left-sided Heart Failure or – Right-sided Heart Failure

• We will focus on heart failure as a general condition

What Is Heart Failure?

89©Pathway Health 2013

http://www.youtube.com/watch?v=GnpLm9fzYxU

• Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs.

• In some cases, the heart can't fill with enough blood. In other cases, the heart can't pump blood to the rest of the body with enough force.

• Some people have both problems.

What Is Heart Failure?

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The term "heart failure" doesn't mean that the heart has stoppedor is about to stop working. However, heart failure is a serious condition that requires medical care.

What Is Heart Failure?

91©Pathway Health 2013

• Right-side heart failure occurs if the heart can't pump enough blood to the lungs to pick up oxygen.

• Left-side heart failure occurs if the heart can't pump enough oxygen-rich blood to the rest of the body.

Overview of Heart Failure

92

©Pathway Health 2013

• Right-side heart failure may cause fluid to build up in the feet, ankles, legs, liver, abdomen, and the veins in the neck

• Right-side and left-side heart failure also may cause shortness of breath and fatigue (tiredness).

Overview of Heart Failure

93©Pathway Health 2013

• Heart failure develops over time as the heart's pumping action grows weaker

• The condition can affect the right side of the heart only, or it can affect both sides of the heart

• Most cases involve both sides of the heart.

Overview of Heart Failure

94

©Pathway Health 2013

• What is it?– A measurement of how much blood the left

ventricle pumps out with each contraction. – Measured as a percentage %

• What it means– An ejection fraction of 60 percent means that 60

percent of the total amount of blood in the left ventricle is pushed out with each heartbeat.

• Normal EF = 55 to 70 percent

Ejection Fraction (EJ)

95©Pathway Health 2013

• What's too low?– A measurement under 40 may be

evidence of heart failure or cardiomyopathy.– An EF between 40 and 55 indicates damage,

perhaps from a previous heart attack, but it may not indicate heart failure.

– In severe cases, EF can be very low.• What's too high?

– EF higher than 75 percent could indicate a heart condition like hypertrophic cardiomyopathy.

Ejection Fraction (EF)

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• You can have a normal EF reading and still have heart failure.

• If heart muscle becomes so thick and stiff that the ventricle holds a smaller-than-usual volume of blood it might still seem to pump out a normal % of the blood that enters it. In reality, the total amount of blood pumped isn't enough to meet your body's needs.

Ejection Fraction and Heart Failure

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• The leading causes of heart failure are diseases that damage the heart.

• Examples include: – Coronary heart

disease (CHD)– High blood pressure– Diabetes– Faulty heart valves– Cardiomyopathy– Myocarditis– Congenital heart

defects– Heart arrhythmias

Leading Causes of Heart Failure

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• Anemia• Arrhythmia (e.g., a-fib)• Chronic hypertension• Chronic lung disease• Coronary artery disease (Angina or MI)• Diabetes mellitus• Excessive alcohol intake

Risk Factors for Heart Failure

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• Fluid volume overload with non-cardiac causes• Idiopathic dilated cardiomyopathy• Medications • Other cardiomyopathy (e.g., Sarcoidosis is a

disease of unknown cause that leads to inflammation. This disease affects your body’s organs.)

• Sleep-disordered breathing• Thyroid disease (hypo or hyperthyroidism)• Valvular Heart Disease (e.g., aortic stenosis, mitral

regurgitation)

Risk Factors for Heart Failure

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• Arrhythmia (e.g. Atrial Fibrillation)• Coronary artery disease• High salt intake• Medications (e.g., antiarrhythmic drugs, calcium

channel blockers, NSAIDs, thiazolidinediones-DM Type II drugs)

• Pulmonary embolism• Renal Failure

Reversible Causes of Heart Failure

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• Severe anemia• Thyroid disease• Uncontrolled hypertension• Valvular heart disease

Reversible Causes of Heart Failure

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• Ascites or sacral edema – Fluid that pools in the abdominal or sacral area. Sacral

edema may be seen when patient is supine.)

• Hypoalbuminemia (Low albumin) • Increased jugular venous pressure• Laterally displaced apical impulse

(Pulse displaced from midclavicular line@ 5th

intercostal space)• Peripheral edema not due to venous

insufficiency

Signs That Suggest Heart Failure

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• Rales on lung exam – Wet and moist

• Tachycardia

• Third heart sound (S3)

• Weight gain – 2 lbs. in one day or – 5 lbs. in one week

Signs That Suggest Heart Failure

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• Abdominal symptoms (nausea, abdominal pain or distention)

• Acute confusion, delirium• Anorexia• Decline in functional status• Decreased exercise tolerance• Decreased food intake• Dyspnea at rest• Dyspnea on exertion

Symptoms That Suggest Heart Failure

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• Fatigue• Orthopnea• Unexplained cough, especially at night• Paroxysmal nocturnal dyspnea• Weakness

Symptoms of Heart Failure

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• Falls

• Decline in energy levels

• Decline in ability to participate in ADLs or activities

• Decrease in sleep quality

• Depression and/or anxiety

Potential Risks

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• Direct-care staff should be trained to recognize and report subtle differences in a patient’s condition, such as:– Clothing (e.g., shoes, pants) appears tight – New or increasing lower-extremity swelling– Patient appears lethargic or mentally sluggish– Patient is less active

What to Teach Direct Care Staff

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– Patient has more difficulty breathing with or without exertion

– Unexplained cough

– Unexpected weight gain • Patients should be weighed at the same time of day, in

the same state of dress, with the same equipment/devices, and on the same scale.)

• Weight gain of 2 lbs. in one day or 5 lbs. in one week

What to Teach Direct Care Staff

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• Monitor and document the following:– Vital Signs– Oxygen saturation level (O2 sats)– Peripheral pulses– Heart and Lung sounds– Blood glucose level– Shortness of breath at rest and with activity– Edema or swelling (lower extremities, sacral,

abdominal, periorbital, etc.)

Assessment

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– Pain level (chest pain, shoulder pain, etc.)– Cough and sputum production– Cyanosis– Daily weights– Intake and output– Activity tolerance, increased lethargy– Capillary refill– Jugular vein distention– Skin turgor

Assessment

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• Complete Blood Count– A reduced red blood cell count (anemia) may

mean that heart failure is caused or aggravated by a decrease in the oxygen-carrying capacity of the blood.

– Even if this is not the case, a low blood count can make the heart work harder and can be dangerous

• Thyroid– Abnormal findings may be a sign that heart

failure is caused or made worse by an underactive thyroid (hypothyroidism) or an overactive thyroid (hyperthyroidism)

Lab Tests

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• Serum electrolytes – People with heart failure need to maintain the

concentration of electrolytes in the blood (particularly sodium, potassium, and magnesium)

• Creatinine– High levels of creatinine may indicate that a

kidney problem is responsible for fluid buildup in the body, not heart failure

Lab Tests

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• Serum levels of BNP- B-type Natriuretic Peptide: – BNP is a substance secreted from the ventricles or lower

chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens.

– BNP is made by the heart and tells how well the heart is working. Normally, only a low amount of BNP is found in the blood.

– However, if the heart has to work harder over a long period of time, such as from heart failure, the heart releases more BNP and the blood level of BNP will get higher.

– The BNP level may drop when treatment for heart failure is working.

– BNP levels below 100 pg/mL indicate no heart failure – BNP levels of 100-300 suggest heart failure is present – BNP levels above 300 pg/mL indicate mild heart failure – BNP levels above 600 pg/mL indicate moderate heart failure. – BNP levels above 900 pg/mL indicate severe heart failure.

Lab Tests

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• Treat exacerbating conditions (e.g., anemia, diabetes, cardiac arrhythmia, infection, fever)

• Treat fluid volume overload, if present.– Start on loop diuretic as prescribed– Monitor weight and blood pressure

Medical Treatments

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• Angiotensin-Converting Enzyme (ACE) Inhibitors– These drugs help people with heart failure live longer

and feel better. – ACE inhibitors are a type of vasodilator, a drug that

widens blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart.

– Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril) and captopril (Capoten).

Medications

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• BUN / Creatinine– Elevated due to decreased perfusion of the kidneys &

diuretic use or low with fluid overload• Hemoglobin / Hematocrit

– Elevated with dehydration or low with fluid overload • Glucose

– May be elevated with stress, diabetes• Chloride

– Low value may indicate increasing or new CHF

Lab Rationales

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• Potassium – Low value may be due to non-potassium sparing

diuretics & certain cardiac drugs– High value may be due to potassium sparing diuretics &

certain cardiac drugs• Sodium

– Low value may indicate fluid overload and dilutionalhyponatremia

– Low value may be a side effect of ACE Inhibitors– High value may indicate dehydration due to diuretics

Lab Rationales

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Myocardial Infarction

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• http://www.youtube.com/watch?v=V_1hxz8XxVk&feature=endscreen&NR=1

Myocardial Infarction

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• Myocardial infarction(MI) or acute myocardial infarction (AMI), commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die.

Myocardial Infarction

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• Most common due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of white blood cells (especially macrophages) in the wall of an artery.

Myocardial Infarction

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• The resulting ischemia (restriction in blood supply) and ensuing oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).

Symptoms of MI

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• Typical symptoms of acute myocardial infarction include:

• Sudden chest pain (typically radiating to the left arm or left side of the neck),

• Shortness of breath• Nausea/vomiting• Palpitations• Sweating• Anxiety• Feeling of indigestion, and fatigue

Symptoms of MI

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Management of MI

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– Anticoagulants: Decreases the clotting (coagulating) ability of the blood

– Antiplatelet Agents: Keeps blood clots from forming by preventing blood platelets from sticking together.

– Angiotensin-Converting Enzyme (ACE) Inhibitors: Expands blood vessels and decreases resistance by lowering levels of angiotensin II. Allows blood to flow more easily and makes the heart's work easier or more efficient.

Cardiac Medications

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– Angiotensin II Receptor Blockers (or Inhibitors): Rather than lowering levels of angiotensin II (as ACE inhibitors do) angiotensin II receptor blockers prevent this chemical from having any effects on the heart and blood vessels. This keeps blood pressure from rising.

– Beta Blockers: Decreases the heart rate and cardiac output, which lowers blood pressure and makes the heart beat more slowly and with less force.

Cardiac Medications

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– Calcium Channel Blockers: Interrupts the movement of calcium into the cells of the heart and blood vessels. May decrease the heart's pumping strength and relax blood vessels.

– Diuretics: Causes the body to rid itself of excess fluids and sodium through urination. Helps to relieve the heart's workload. Also decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs. Different diuretics remove fluid at varied rates and through different methods.

Cardiac Medications

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– Vasodilators: Relaxes blood vessels and increases the supply of blood and oxygen to the heart while reducing its workload. Can come in pills to be swallowed, chewable tablets and as a topical application (cream).

– Digitalis Preparations: Increases the force of the heart's contractions, which can be beneficial in heart failure and for irregular heart beats.

Cardiac Medications

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• Statins: Various medications can lower blood cholesterol levels. They may be prescribed individually or in combination with other drugs. They work in the body in different ways. Some affect the liver, some work in the intestines and some interrupt the formation of cholesterol from circulating in the blood.

Cardiac Medications

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• Thrombolysis: – Many heart attack patients have undergone

thrombolysis, a procedure that involves injecting a clot-dissolving agent to restore blood flow in a coronary artery.

– This procedure is administered within a few (usually three) hours of a heart attack.

Cardiac Medications

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– Coronary Catheterization (Angiogram): A procedure that doctors do first to locate narrowed arteries to the heart.

– Coronary Angioplasty and Stenting: Emergency angioplasty opens blocked coronary arteries, letting blood flow more freely to your heart.• Depending on your condition, your doctor may opt to

place a stent coated with a slow-releasing medication to help keep your artery open.

Cardiac Procedures

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– Coronary Artery Bypass Graft (CABG): Bypass surgery involves sewing veins or arteries in place at a site beyond a blocked or narrowed coronary artery (bypassing the narrowed section), restoring blood flow to the heart.• Once blood flow to your heart is restored and your

condition is stable following your heart attack, you may be hospitalized for observation.

Cardiac Procedures

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– Artificial Heart Valve Surgery– Atherectomy– Cardiomyoplasty– Heart Transplant– Radiofrequency Ablation– Transmyocardial Revascularization (TMR)

Cardiac Procedures

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– Pacemaker: A small device that has wires which are implanted in the heart tissue to send electrical impulses that help the heart beat in a regular rhythm. The device is powered by a battery.

– Left Ventricular Assist Device (LVAD): A left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that's surgically implanted. It helps maintain the pumping ability of a heart that can't effectively work on its own.

Implantable Medical Devices

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• Implantable Cardioverter Defibrillator: A device that has wires which are implanted into the heart tissue and can deliver electrical shocks, detect the rhythm of the heart and sometimes "pace" the heart's rhythms, as needed.

Implantable Medical Devices

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• Professionally supervised program• A program divided into phases that involve

various levels of:– monitored exercise– nutritional counseling– emotional support and counseling– support and education about lifestyle changes

to reduce the risks of heart problems

Cardiac Rehabilitation

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• Increase physical fitness• Reduce cardiac symptoms• Improve health• Reduce the risk of future heart problems

Benefits of Cardiac Rehab

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Urinary Tract Infections

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• Urinary tract infections are a significant cause of morbidity in this population

• UTI’s can cause complications such as urosepsisand the need for hospitalization.

UTIs

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• Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeerCriteria

• First update since 1991

New Surveillance Definitions

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• Fever

• Leucocytosis

• Acute change in mental status from baseline

• Acute functional decline– Bed mobility, transfer, locomotion, dressing,

toilet use, personal hygiene, eating

Constitutional Criteria

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1. Old definition (from 1991) Temp.> 100.4 in criteria from 1991

2. New definition (from 2012)1. A single oral temperature greater than

37.8C (1000F) or 2. Repeated oral temperatures greater than

37.2C (990F) or rectal temperatures greater than 37.5C (99.50F) or

3. A single temperature > 1.1C (2.00F) from baseline

3. Lower febrile response in the elderly

New Fever Definition

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• MDS 3.0, Section C, Cognitive Patterns– Inattention

• Easily distracted, out of touch or difficulty following what was said

– Disorganized thinking• Rambling or irrelevant conversation, unclear or illogical

flow of idea, or unpredictable switching from subject to subject

– Altered level of consciousness• Vigilant, lethargic, stuporous, comatose

– Psychomotor retardation

CAM – Confusion Assessment Method

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• At least one of the following – Acute dysuria or acute pain, swelling, or

tenderness of testes, epididymis, or prostate– Fever or leukocytosis and at least one of the

following:• Acute costovertebral angle pain or tenderness,

suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency

– If no fever or leukocytosis, then 2 or more of the following:• Suprapubic pain, gross hematuria, new or marked

increase in incontinence, new or marked increase in urgency, new or marked increase in frequency

New UTI Criteria (1 of 2)

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• AND

• One of the following microbiologic subcriteria– At least 105 cfu/mL of no more than 2 species

of microorganisms in a voided urine sample– At least 102 cfu/mL of any number of

organisms in a specimen collected by in-an-out catheter

New UTI Criteria (2 of 2)

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• At least one of the following:– Fever, rigors, or new onset hypotension, with no

alternate site of infection– Either acute change in mental status or acute functional

decline with no alternate diagnosis and leukocytosis– New onset suprapubic pain or costovertebral angle pain

or tenderness– Purulent discharge from around the catheter or acute

pain, swelling, or tenderness of the testes, epididymis, or prostate

AND• Urinary catheter specimen culture with at least

105 cfu/mL of any organism(s)

New UTI Criteria with Catheter

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UTI Presentation in the Elderly

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• Symptoms of a urinary tract infection, can be easily overlooked, causing a delay in diagnosis.

• Elderly people with a UTI are more likely than younger people not to be diagnosed until the complication of sepsis occurs.

• May exhibit vague symptoms; May mimic many diseases

• May be assumed to be due to the aging process.

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• “Urine specimens for culture should be processed as soon as possible, preferably within 1–2 h.

• If urine specimens cannot be processed within 30 min of collection, they should be refrigerated. Refrigerated specimens should be cultured within 24 h.”

Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria, pg. 971

UTIs

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• “Recent catheter trauma, catheter obstruction, or new onset hematuria are useful localizing signs that are consistent with UTI but are not necessary for diagnosis.

• Urinary catheter specimens for culture should be collected following replacement of the catheter (if current catheter has been in place for >14 d).”

Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeerCriteria, pg. 971

Urinary Catheters

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• Goal of treating a UTI is to alleviate systemic or local symptoms, not to eradicate all bacteria.

• A post-treatment urine culture is not routinely necessary

• Continued bacteriuria without residual symptoms does not warrant repeat or continued antibiotic therapy.

• Recurrent UTI’s (2 or more in 6 months) may warrant further evaluation -- PVR or referral to urologist.

Follow Up of UTIs

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• An illness in which the body has a severe response to bacteria or other germs.

• This response may be called systemic inflammatory response syndrome (SIRS).

Sepsis

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• The symptoms of sepsis are not caused by the germs themselves. Instead, chemicals the body releases cause the response.

• A bacterial infection anywhere in the body may set off the response that leads to sepsis.

Causes of Sepsis

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• B/P drops, resulting in shock.

• Major organs and body systems, including the kidneys, liver, lungs, and central nervous system, stop working properly because of poor blood flow.

• A change in mental status and very fast breathing may be the earliest signs of sepsis.

• Chills, confusion or delirium, fever, light-headedness, rapid heartbeat, shaking, skin rash, warm skin

Symptoms of Sepsis

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• The person will look very sick!

• Antibiotics may mask signs of infection in a blood test.

• Blood differential, blood gases, kidney function tests, platelet count, WBC

Signs & Tests for Sepsis

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• ICU• IV antibiotics• Oxygen• IV fluids• Medications to increase B/P• Dialysis if there is kidney failure• Mechanical ventilation (vent) if there is lung

failure

Treatment of Sepsis

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• Sepsis is often life threatening, especially in people with a weakened immune system or a chronic illness.

• Damage caused by a drop in blood flow to vital organs such as the brain, heart, and kidneys may take time to improve.

• There may be long-term problems with the above organs.

• No all persons survive an episode of sepsis.

Prognosis

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• Immunizations

• Careful hand washing

• Proper care of urinary catheters and IV lines

• Early interventions

Prevention of Sepsis

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Advance Directives have not delivered on their promise

–Approximately 25% of adults have an AD –Most do not understand how they will be used –Often not available when needed –Not useful for medical decisions in progressive

illness

ADVANCE CARE PLANNING Wilkinson A, Wenger N, Shugarman LR; U.S. Department of Health and Human Services; RAND Corporation. Literature Review On Advance Directives. http://aspe.hhs.gov/daltcp/reports/2007/advdirlr.htmPublished June 2008.

Advance Care Planning Concerns

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To make a difference, we must change our focus away from forms and toward work systems

– Proactive communication about stages of illness and progressive frailty

– Anticipate complications

– Use values to set goals

– Use goals to make decisions

– Offer specific alternatives

Advance Care Planning

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Advance Care Planning

A process of communication about anticipated medical choices throughout the adult lifespan, focused on patient

goals and values

161©Pathway Health 2013

• The MD is responsible for discussing the illness, future issues, risks and benefits of various treatments and writing orders consistent with preferences

• But, ACP is an interdisciplinary team responsibility

• Good decisions that honor resident preferences must be made with a health care team the resident and their decision makers trust

Medical Staff Responsibilities

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• Staff Roles with ACP Physician/Nurse Practitioner/Physician Assistant Educate resident and family on what to expect Document discussions

• Advance Care Planning Key Resources Conduct Advance Care Planning discussions

• All Clinical Staff Be knowledgeable about treatment options

• All Staff Be alert for changes, signs of changing goals

Advance Care Planning

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1. Assess the Current Situation – Number and percent of residents with

documentation of initial discussion – Number and percent of residents with advance

directives, living will, and a health care surrogate decision maker

– Deceased chart review – were decisions documented and honored?

– Approaches currently used and people responsible for implementation

http://www.nhqualitycampaign.org/files/impguides/6_AdvanceCarePlanning_TAW_G

Seven Steps to Improve ACP

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2. Select ACP as an area for potential improvement based upon preliminary assessment – buy- in and accountability needed

3. Review state laws and regulations & current information on ACP (see Resources)

Seven Steps to Improve ACP

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4. Identify areas for improvement in processes and practices including:

• Current policies and protocols

• Actual practice related to ACP

• Issues that have arisen related to ACP

• Previous attempts to address need for

improvement

Seven Steps to Improve ACP

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5. Identify the desired process and outcomes •Identify barriers and challenges •Develop strategies to overcome issues

6. Reinforce practices that are already optimal

7. Implement needed changes and re-evaluate; Be specific about what is being measured

Seven Steps to Improve ACP

167©Pathway Health 2013

• Communicating with residents, families, and other health care decision makers

• Providing examples of comfort care measures

• Hard wire ACP initiation, review and communication into facility practices

INTERACT ACP Tools

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Comfort care, whether or not the resident is enrolled in a hospice program, should include standard orders that address:

• Nutrition and hydration

• Activity

• Monitoring in the least disruptive way

• Hygiene

• Comfort and safety

Advance Care Planning

169©Pathway Health 2013

Physician Orders

Comfort care orders should also anticipate symptoms that can cause distress and discomfort, such as:

• Shortness of breath, dyspnea, & terminal stress

• Pain

• Anorexia

• Anxiety

• Seizures

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Advance Care Planning

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Advance Care Planning

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Advance Care Planning

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Thoughts

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Pathway HealthWhite Bear Lake, MN

www.pathwayhealth.com877-777-5463

Thank You

175

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