Transcript 2012 CCU Competency

2012 CCU
COMPETENCY
HF Module 2: Nursing
Driven Care and Quality
Outcomes
GOALS FOR THIS MODULE
Assessment of dyspnea
Volume status
Self care management:
Focus on diet and medications
Transitions of care
ASSESSMENT OF DYSPNEA
 Congestion is the most
common reason for HF
admissions.
 Dyspnea is the most
common symptom
associated congestion.
 Improvement in dyspnea is a
 When assessing for dyspnea it is
important to include the following in
your assessment:
 Is your assessment at rest or with exertion?
 If the assessment is with exertion – how much
exertion?

This is why it is important for HF patients to
participate in Phase I Cardiac Rehab to allow for
a systematic way to assess activity tolerance.

Each step in Phase I Cardiac Rehab is associated
with a metabolic equivalent of activity which can
be translated to activities of daily living.

It is also important to know if the patient
becomes dyspneic with minimal exertion such as
talking or changing positions in the bed.
primary goal of treatment.
 If dyspnea is at rest, it is important to know if
the patient is dyspneic in the full upright
position or when lying flat (orthopnea).
VOLUME STATUS
 Many patients who are congested are volume overloaded.
 However, it is possible to have pulmonary congestion without significant
volume overload. This often occurs in HF patients who are
hypertensive. An increase in hydrostatic pressure can push fluid out of
the vascular space and place the patient at risk for flash pulmonary
edema.
 Daily weight and I&O are two important tools used to assess volume
status.
 The process for accurate I&O is already well defined through CCU
Shared Decision Making and is an expectation for everyone.
 The results of the daily weight should match the results of the 24 hour
I&O. For example: A negative fluid balance on I&O should correspond
to a decrease in the daily weight.
VOLUME STATUS
 Daily weights need to be completed on every patient admitted with HF as well
as anyone with a history of HF (Remember: We have instructed these patients
to weigh daily at home).
 Always indicate the type of scale used for obtaining a daily
weight.
 If the patient is able to stand, a standing scale should always be used. This
reinforces the patient’s involvement in care.
 If a bed scale is used, the weight should be done with a bottom sheet, one
pillow, a pull pad, a top sheet, and one blanket only according to hospital
guidelines. Please remember to calibrate the bed before admitting the patient
in the bed.
 When a patient is able to be transferred from bed weight to scale weight, both
weights need to be recorded on the day of transition. There will always be
some variation between the two methods and thus both weights need to
recorded at the time of transition to allow for comparison between weights
recorded in the same way.
Day 1 Bed Scale
79.9 kg
Day 2 Bed Scale
78.3 kg
Day 3 Bed Scale
76.9 kg (down 1.4 kg when comparing bed scale to bed scale)
(down 1.6 kg)
Day 3 Standing Scale 75.9 kg
(*down 2.4 kg when comparing bed scale to standing scale)
Day 4 Standing Scale 76.3
(up 0.4 kg when comparing standing scale to standing scale)
(*down 0.6 kg when comparing standing scale to bed scale)
EXAMPLE: * Note the inaccurate conclusions that are
drawn when comparing two different scales, including the
difference between a weight loss and a weight gain.
SODIUM RESTRICTION AND VOLUME STATUS
Except for unusual circumstances – the patient with HF should be on a sodium restricted diet
of 2 grams of sodium per day. Please advocate for your patients by assuring a 2 gram sodium
diet is ordered.
Water follows sodium and the failure to restrict sodium can interfere with the ability to
effectively diurese.
HF patients who are hyponatremic are usually hyponatremic because they have an excess of
free water in relationship to normal sodium. The treatment is to restrict fluid rather than add
salt. These patients should also be a sodium restricted diet because liberalizing sodium will
increase the thirst mechanism.
Note: Many HF patients are at risk for hyperkalemia due to renal dysfunction,
ACE-I or ARB, and aldosterone antagonists. These patients need instructed to
avoid salt substitutes that contain potassium chloride.
SELF CARE MANAGEMENT
 Last year’s competency focused on patient education skills
related to self care management .
 The self care skills with opportunity for improvement
included:
 Reliable system to remember to take medications.
 Ability to read food labels and / recognize restaurant foods high in
sodium.
 Home scales with the ability to see and record daily weights.
 Decision making ability to recognize reportable symptoms.
2012 FOCUS
 We want to build on what we learned about self care and focus on
specific skills we can incorporate into practice to support self care.
 There are three areas of patient education we want to focus on for
2012.
 Documentation of a total of one hour of patient education for each heart failure
patient.
 Utilization of HF videos.
 Involvement of primary caregiver in education sessions and discharge instructions.
2012 FOCUS
There are also three specific self care skills
we want to focus on during 2012.
 Use of actual food labels when teaching patients about a
low sodium diet.
 Medication clarity.
 Identifying where patients will record daily weights and
what the patient response will be to an increase in
weight gain.
FOOD LABELS
 To assist with patient education of self care skills we have created large
laminated labels that can be used to teach patients how to evaluate the
sodium content. Two sample labels are shown on the next slide.
 Although we often tell our patients to eat a low salt diet, many patients
do not have the skills necessary to implement a low salt diet into their
daily lives.
 Patients need to know that sodium means salt on a food label.
 They also need to know that the amount of sodium listed is per serving.
 A general rule is for patients to eat foods that are < 10% daily value of
sodium per serving.
SAMPLE FOOD LABELS: TO BE ENLARGED AND
LAMINATED FOR PATIENT EDUCATION
 We want to use the
SOAR method as a specific strategy to improve patient
adherence and safety with prescribed medications. The SOAR method is a
method developed specific for CCU competency and the HF population.
S = Stop medications.
Please include all previous home medications the patient is
to stop taking as part of the discharge instruction process.
O = Over the counter medications.
Please instruct HF patients not to take any
non steroidal over the counter medications like ibuprofen (Advil) or naproxen
(Aleve). These medications can contribute to worsening renal function.
A = Affordability.
Please inform the case manager, APN, or physician of any financial
concerns.

R = Remember system. Please specifically ask the patient / caregiver to identify
the system they are going to use to remember to take medications and remember
to take their medication list with them to every provider appointment.
MEDICATIONS
DAILY WEIGHT RECORDING AND
RESPONSE
 There are new daily weight log sheets available for patients to use.
 Note: Patients should be encouraged to use their own system for recording daily weights if
they already have one.
 Patients should be instructed to use the first weight the morning after
discharge as the starting weight.
 Patients need to know to bring a daily weight sheet to each physician office
visit.
We are going to begin tracking how
often patients bring a daily weight
sheets to their first HF cardiology
visit.
DAILY WEIGHT RECORDING AND
RESPONSE
 It is also important for patients to know exactly what to do if they have
a weight gain of > 2 lbs in one day or > 3 lbs in one week.
 Patients need to know specifically which physician to call for an increase in weight
gain.
 Any patient seen by cardiology should have an appointment within one week of discharge.
Patients should be instructed to call the cardiology office for any problems with their
weight prior to the first follow up visit.
 If a patient has not been seen by cardiology then they should be instructed to call their PCP
or the physician who routinely manages their HF.
 Some patients will have instructions to take additional diuretic in response to weight
gain.
 These patients will need extra education to assure they thoroughly understand how to
dose the extra diuretic.

Taking additional diuretic may require extra potassium supplementation and / or more
frequent lab draws. Please make sure any additional requirements are clear to the patient
and caregiver.
General Patient Education Areas for Focus:
One Hour of Patient Education
 One hour of documented HF education
 This is a new quality indicator for an initiative called Target HF which is offered
through the American Heart Association.
 The one hour of HF education is a new indicator because the study references
below showed that one hour of nurse education at the time of discharge made a
difference in patient outcomes.
 Although we are not looking for one continuous time period for the hour of
education, we are looking for a minimum of one hour total time of HF education.
 Remember – this patient population is a high risk vulnerable patient population with
very special education needs.
 Data collection was imitated in the fall of 2011 and only 11/180 or 6.1% had a total
of hour of HF education!!
 Our goal is to achieve 85% after everyone has completed the competency modules.
Koelling, T. M. , Johnson, M.L., Cody, R.J., & Aaronson, K.D. (2005). Discharge Education Improves
Clinical Outcomes in Patients With Chronic Heart Failure, Circulation, 111, 179-185
doi: 10.1161/01.CIR.0000151811.53450.B8
General Patient Education Areas for Focus:
Video Use
 We focused on HF video use during 2011 competency. Before
competency we assessed our baseline use of video education in our HF
population.
 The next slide compares 5 months of pre competency video use with
the next 5 months after we initiated the competency module. As you
can see there was NO significant improvement.
 Our goal for 2012 is that 75% our HF patients watch at least one HF
video. We will share the results of this data with you during the annual
competency meeting.
Remember: It is not just showing the HF
education video, you must ask the patients
to teach back what they have learned.
HF VIDEO USE COMPARISON DATA
Heart Failure Video
Education
Participation
Number (1/1 –
5/31 2011)
Participation
Number (6/1 –
10/31 2011)
Note: 211 HF
patients in CCU!
Video 100: HF Treatment –
Getting Started
26
18
Video 117: Nutrition for HF
Patients
17
25
Video 118: Exercise for HF
Patients
3
2
Video 119: Understanding HF
Medications
1
11
Video 120: Emotions and HF
Management
3
0
10
9
Video 212: Congestive HF (2nd
Ed.)
General Patient Education Areas for Focus:
Education Including Primary Caregiver
 The primary caregiver is often frail and sometimes is not able to
frequently visit in the hospital (Hospital to Home Initiative). It may take
a special effort to have them present for important information.
 The primary caregiver is often responsible for meal preparation and
medication administration. For this reason it is important that person is
identified and involved in the education process.
 We are asking everyone to do two things when educating the HF
patient:
 1) Identify the primary caregiver
 2) Assure the primary caregiver is included in the education process.
 This may require a telephone call or discussion with other family members in order to get
the primary caregiver at the bedside for education.
TRANSITIONS OF CARE
NATIONAL TRANSITIONS OF CARE
COALITION
Patient’s Bill of Rights During Transitions of
Care
Transitions of care take place each time a patient
goes from one health care provider or health care
setting to another. Problems often happen during
these transitions because information is not
communicated. Patients and their family have the
right to care transitions that are safe and well
coordinated.
One important aspect of transitioning care with the HF patient is the first
office visit post discharge.
TRANSITION OF CARE IN HF
 A vulnerable period for readmission is within the first week
following discharge.
 For this reason one of the new criteria for the American
Heart Association Get with the Guidelines is for all HF
patients to have a follow up appointment within one week
of discharge.
 To help meet this standard Kathy Evans has been working
with the CVC APNs and with Colleen Motts (Aultman’s HF
Coordinator) for non CVC patients to get an appointment
within one week of discharge.
 It is important that the provider, date and time be listed in
the discharge instructions. It is not acceptable to say “Call
Dr. _______ for an appointment in one week.”.
FOLLOW UP APPOINTMENT
OUR SUCCESS WITH ONE WEEK
APPOINTMENTS
 Initial Aultman Hospital data collected in 2011 showed 28 of 103
patients or 27.2% of HF patients had a discharge appointment within
one week of discharge.
 January 2012 data showed that 39/84 or 46.4% of HF had a discharge
appointment within one week of discharge.
 There has been an improvement but we are not yet where we need to
be.
 If you are discharging a HF patient that is being seen by CVC (admitting or
consulting) and there is not an appointment (date, time, and provider) for within one
week of discharge please call the APN who is covering your POD.
 If the patient is not being seen by CVC you can discuss with the discharging physician
or page the HF nurse.
CVC FOLLOW UP APPOINTMENTS
 HF patients being seen by a CVC cardiologist during their hospital stay
will have their one week follow up appointment made in the HF clinic
within the CVC office.
 The HF clinic appointments are with an advanced practice nurse (APN)
or physician assistant (PA) within the CVC practice. The APN and PA
have access to a cardiologist during the HF clinic appointment if needed.
The most current data from the HF clinic
show that 40% of the one week HF
appointments are no shows.
CVC FOLLOW UP APPOINTMENTS
 When discharging a HF CVC patient with a one week appointment, it is
important to be accurate about whom the follow up appointment is
with. The names of the APN or PA should be circled or written on the
appointment card.
 Also – please stress with the patient the importance of keeping this first
one week appointment (even if it is within a day or two after discharge).
 During this appointment the next appointment with the cardiologist will be made.
 Additionally, a report will be sent to the primary care physician communicating all
aspects of HF care.
SPECIAL INSTRUCTION REGARDING FIRST
HF CLINIC VISIT
 There will be a one page handout to give to patients along
with their appointment card, that describes the purpose of
the first HF visit.
 Please instruct patients and families to bring all their
prescription and over the counter medications in a plastic
or brown paper bag to their HF clinic appointment.
 An important aspect of this first visit will be to review all patient
medications.
FYI: NEW HF CERTIFICATION
 For anyone who might be interested – there is a new heart failure
certification exam for nurses offered by the American Association of Heart
Failure Nurses.
 To be eligible for this certification a nurse must first have 30 hours of
continuing education in heart failure to be eligible for certification.
 You do not need to have a CCRN or PCCN certification to sit for the
heart failure certification exam.
 If interested check out the following website:
http://www.heartfailurecertification.com
REMEMBER:
We must not, in trying to think
about how we can make a big
difference, ignore the small daily
differences we can make which,
overtime, add up to big differences
that we often cannot foresee.
-Marian Wright Edelman
29
TO COMPLETE THIS MODULE:
 To complete this module please bring examples of the
following to your annual competency meeting. Please
include these examples in your professional portfolio.
 Bring an example(s) of patient self care education you were involved in
specific to: a) label reading for sodium, b) the SOAR method for medication
adherence and compliance, or 3) instruction regarding recording and
response to daily weights.
 Bring an example(s) of how you have supported: a) involvement of the
primary care giver, b) documentation of one hour of patient education, or c)
viewing and teaching back of the HF videos.
 Obtain or maintain certification as a
CCRN, and / or CMC, or HF certified
nurse.
 Submit a peer review written statement
or a self reflective written statement (in
your portfolio) demonstrating how you
have shown clinical leadership in the
area of teaching patients self care skills
related to low sodium diet, medication
adherence and safety, and or daily
weight recording and reporting as
discussed in this module.
 Read an evidence based patient
education journal article on heart
failure management; identify how this
article will change your practice and
bring to your individual competency
meeting.
 Volunteer to serve on the Heart
Center HF Work Group. Let Rhonda
know if you are interested.
Your Choice Activity:
Choose One of the
Activities to the Left.
(your
choice activity will be discussed at your
competency meeting).
Literature supports that
professional nurses should take
ownership in validating their
own competency.
Source: National Education Framework Cancer
Nursing, 2008