SIMULATION. SKILL FOCUS: Perform Skills Procedures with Checklists DISCIPLINE: Medical Assistant LEVEL: 2 HEART FAILURE

Transcription

1 SKILL FOCUS: Perfrm Skills Prcedures with Checklists DISCIPLINE: Medical Assistant LEVEL: 2 HEART FAILURE Estimated Time: 30 minutes Debriefing Time: 30 minutes Scan t Begin Patient Name: Hectr Fernandez SCENARIO OVERVIEW Hectr Fernandez is a 62-year-ld Hispanic male patient wh presents t a clinic fr a rutine fllw-up visit fr his heart failure. He als needs a urinalysis and capillary puncture (bld glucse) at this visit. Students btain a patient histry and vital signs, perfrm medicatin recnciliatin, btain a capillary bld glucse, instruct patient n hw t supply a clean catch midstream urine sample, and describe hw t btain the results using urinalysis reagent strips. Images f the supplies needed t accmplish these tasks are displayed as the student prgresses thrugh the scenari. HEART FAILURE SIMULATION UPDATED: JULY 25,

2 LEARNING OBJECTIVES 1. Demnstrate prfessinalism in a healthcare setting 2. Practice standard precautins 3. Obtain vital signs 4. Obtain patient histry 5. Emply elements f therapeutic cmmunicatin based upn theries f psychlgy 6. Assist physician with patient care: rutine examinatins 7. Analyze the causes, signs and symptms, diagnsis, treatment, and preventin f cmmn diseases and disrders f the cardivascular system 8. Instruct patients in the cllectin f specimens 9. Perfrm capillary puncture and btain bld glucse reading 10. Obtain clean catch midstream urine sample and perfrm urinalysis using reagent strips CURRICULUM MAPPING WTCS PROGRAM OUTCOMES Prvide patient care in accrdance with regulatins, plicies, laws, and patient rights Demnstrate prfessinalism in a healthcare setting Demnstrate safety and emergency practices in a healthcare setting HEART FAILURE SIMULATION UPDATED: JULY 25,

3 SIMULATION LEARNING ENVIRONMENT & SET-UP PATIENT PROFILE Name: Hectr Fernandez DOB: 09/06/19xx Weight: 86.4 kg (190 lbs) Allergies: Penicillin Age: 62 MR#: Gender: Male Height: 175 cm (5 ft 10 in) EQUIPMENT/SUPPLIES/SETTINGS Patient Cde Status: Full Cde Ethnicity: Hispanic Spiritual Practice: Cathlic Primary Language: Spanish Street clthes Has Ziplc bag f varius medicatins with him Medicatin bttles can be blank with the varius QR cdes belw attached t each bttle fr students t view a realistic label. Otherwise, t create yur wn labels the medicatins are: Aspirin 81 mg PO Fursemide 40 mg PO Lisinpril 10 mg PO Metprll tartrate 25 mg PO Atrvastatin 40 mg PO Digxin mg PO Acetaminphen 500 mg PO Regular insulin vial Lantus insulin vial HEART FAILURE SIMULATION UPDATED: JULY 25,

4 Mnitr Settings Vitals: HR 68, RR 15, BP 188/94, Temp 37.4, O2 sat 100% n RA, Pain 2/10 Supplies Equipment t btain vitals including xygen saturatin HEART FAILURE SIMULATION UPDATED: JULY 25,

5 QR CODES REPORT PATIENT LEG BLOOD GLUCOSE MONITOR BOTTLE OF URINALYSIS STRIPS URINE SPECIMEN CUP URINALYSIS REAGANT STRIP BLOOD GLUCOSE RESULT ATORVASTIN DIGOXIN FUROSEMIDE LISINOPRIL METOPROLOL ACETAMINOPHEN ASPIRIN FACILITATOR HEART FAILURE SIMULATION UPDATED: JULY 25,

6 TEACHING PLAN PREBRIEF The facilitatr shuld lead this prtin f the simulatin. The fllwing steps will guide yu thrugh Prebrief. Scan the QR cde: Scan t Begin while students are in Prebrief. Meet Yur Patient (n ipad) and explain hw the ipad wrks in the simulated learning envirnment including: Explain hw t use the ipad scanner and QR cdes. Remind students that there are multiple QR cdes in the simulatin, but they shuld nly scan them if they think it will prvide data necessary fr their assessment and evaluatin f the patient. As the facilitatr, yu shuld be aware that thrughut the simulatin sme QR cdes are necessary t the prgramming f the ipad cntent. Directins fr which QR cdes are required (t be scanned) in each state are listed under each state f the dcumentatin belw. The QR cdes are als in BOLD type. Discuss the simulatin Learning Objective(s) (n ipad) as well as any ther Prebrief materials Get Reprt n ipad Pssible Facilitatr Questins What are yur pririties when yu are rming a patient with heart failure? Play the Patient vide n ipad Pssible Facilitatr Questins After listening t the patient s statement, is there anything yu wuld like t add t yur plan? Advance t the Patient Prfile screen (n ipad). This will act as a simulated patient chart. Students can view the tabbed cntent n the ipad (see belw) prir t entering the patient s rm and thrughut the simulatin as needed. HEART FAILURE SIMULATION UPDATED: JULY 25,

7 CHECKLISTS Prcedure checklists fr btaining a capillary bld glucse, btaining a clean catch midstream urine specimen, and perfrming a urinalysis using reagent strips are lcated here. Cpies are als lcated in Appendix B t ptinally print ut fr student use. VITALS The ipad shws the enterable vitals screen. PROBLEM LIST Prblem List If values are entered, they are checked fr accuracy against fllwing values (+/- 5): HR 68, RR 15, BP 188/94, Temp 37.4, O2 sat 100% n RA, Pain 2/10 Currently Knwn Medical Prblem(s) 1. Chrnic Heart Failure, NYHA Class 2 2. Crnary Artery Disease 3. Diabetes Type 2 4. Chrnic Kidney Disease, G3a 5. Obstructive Sleep Apnea 6. Hypertensin 7. Ostearthritis 8. Tinea pedis, recurrent 9. Gastresphageal Reflux 10. Allergies, seasnal CURRENT MEDICATION LIST Facilitatr Nte: This is an enterable frm fr students t use t enter medicatin infrmatin. QR cdes fr varius medicatins are prvided abve t simulate medicatin bttles. By typing the first few letters in the bx labelled Medicatin, a list f pssible medicatins and dsages appear fr the student t tap t select. The instructins/prescriptin fr hw t take the medicatin shuld be entered in the bx labelled Ntes, then tap Submit. The medicatin will appear in the list, with a hyperlink prvided t read mre abut the medicatin. Students may als tap Discntinue t remve the medicatin frm the list. HEART FAILURE SIMULATION UPDATED: JULY 25,

8 Metprll Succinate and Tartate are bth drp-dwn ptins t stimulate discussin abut the difference between the tw medicatins. The Facilitatr shuld scan the QR Cde: Facilitatr t indicate when students have cmpleted the medicatin recnciliatin accurately. Once this cde is scanned, the ipad will lead them thrugh a series f tasks, as described under State 1. PATIENT EDUCATION Patient Educatin handut n Heart Failure is prvided under this tab. Appendix A cntains a printable Patient Educatin handuts fr ptinal student use. EMERGENCY CONTACT INFORMATION Emergency Cntact Infrmatin Cntact Cntact Infrmatin Wife: Maria Fernandez Phne: Address: 220 Suth Main Street Anytwn, WI LEVEL When the Level 1 tab is tapped, the ipad reads, The ipad is at Level 1. SCANNER Use this t scan available QR cdes. EXIT The ipad reads, Are yu sure yu want t exit? All data will be lst. HEART FAILURE SIMULATION UPDATED: JULY 25,

9 If N is selected, the ipad will return t the tabbed cntent. If Yes is selected, the ipad will let the student(s) exit and prmpt them t cmplete an embedded 3-5 minute survey. HEART FAILURE SIMULATION UPDATED: JULY 25,

10 STATE 1 OBTAIN PATIENT INFORMATION Patient Overview Patient is returning t the clinic fr a fllw-up visit fr chrnic heart failure. He brught all the medicatins he has been taking in a Ziplc bag. Expected Student Behavirs Intrduce themselves t the patient Verify patient identity with name and date f birth Cmmunicate therapeutically regarding patient cncerns Obtain and dcument vital signs accurately Enter medicatins apprpriately int medicatin recrd. Students may scan QR cdes fr varius medicatins abve that simulate medicatin bttles. (See instructins fr entering medicatins under the medicatins tab abve.) After medicatins are entered accurately, the Facilitatr shuld scan the QR Cde: Facilitatr t indicate the student is ready t prceed t the remaining tasks. The ipad will immediately display an image f a urine specimen cup with the message, Verbalize hw yu will instruct Mr. Fernandez t btain a urine sample fr a urinalysis. (Students may view a checklist n hw t btain a clean catch midstream urine sample.) The ipad will then display an image f urine reagent strips with the message, Verbalize the steps yu will take t analyze the urine using the reagent strips. (Students may view a checklist n hw t test urine using reagent strip.) An image f a dipped reagent strip next t the bttle will display with the message, Verbalize the key cmpnents checked in a urine dipstick test. An image f a glucmeter and lancets will display with the message, Verbalize the steps yu will take t btain a capillary bld glucse reading. (Students may view a checklist n hw t btain a capillary bld glucse.) HEART FAILURE SIMULATION UPDATED: JULY 25,

11 An image f a glucmeter with the results 165 appears, with the text: Verbalize the meaning f this result in terms f Mr. Fernandez s diabetes disease prcess. Technician Prmpts At this pint, students receive a message that they have cmpleted the learning bjectives and may exit the scenari. The facilitatr can request that they cmmunicate their findings with the prvider befre exiting. They may als prvide patient educatin using the handut prvided under the Patient Educatin tab. Patient brught his medicatins in, but des nt understand what they are fr, r hw t take them as prescribed. There is smewhat f a language barrier since his primary language spken is Spanish. He can speak English, but des nt understand medical ling. Initial patient respnses can include: They tld me I have a failing heart... But I dn t knw what that means. When I feel shrt f breath, I take all f the medicine in this bag. On days I feel well, I dn t take anything. If students ask abut the patient s current weight, yu may simulate measuring weight then state result is 200 punds. Ask them t cnvert this t kg. If students ask the fllwing questins, prvide these respnses: D yu feel shrt f breath tday? Answer: A little. D yu have a cugh? Answer: Yes, smetimes. Is yur cugh prductive? I dn t understand what prductive means. D yu bring up anything when yu cugh? Yes, smetimes. What des it lk like? HEART FAILURE SIMULATION UPDATED: JULY 25,

12 White and what wrd d yu use... frthy. D yu take any ther medicatins? When I have pain and it wn t g away with this medicatin, my wife gives me ne f her pain pills. D yu knw what medicatin yur wife gives yu? N. It is pquit and white. D yu smke? Yes. Des anyne in yur husehld smke? Yes, my wife des. Hw much alchl d yu drink? A cuple every day when I get hme frm wrk. D yu watch hw much chlesterl, fat and salt yu eat? I m nt sure, I just eat what my wife gives me. What kind f fd d yu generally eat every day? Cffee and eggs, trtillas, burrits and refried beans. Pssible Facilitatr Questins What are general tpics t address when prviding care fr a patient with heart failure? Hw will yu mdify yur apprach fr smene wh des nt speak English as their primary language? What caching is imprtant t prvide patients fr with heart failure fr self-management f their cnditin at hme? What is the nrmal range f a capillary bld glucse? What d these results indicate? Hw will yu mdify yur apprach fr explaining a medical prcedure fr smene wh des nt speak English as their primary language? What infrmatin is gained by perfrming a urinalysis? HEART FAILURE SIMULATION UPDATED: JULY 25,

13 Why is it imprtant t fllw the prcedure fr btaining a midstream clean catch urine sample? EXIT After the QR Cde: Facilitatr is scanned, when this tab is tapped, a message will display: Scenari bjectives have been met. Are yu sure yu want t exit the game? Yes/N HEART FAILURE SIMULATION UPDATED: JULY 25,

14 DEBRIEF Nthing needed frm the ipad. QUESTIONS 1. Reactin: Hw d yu feel this scenari went? (Allw students t vent their emtinal reactins befre delving int learning bjectives.) 2. Review understanding f learning bjectives: Demnstrate prfessinalism in a healthcare setting a. Hw did yu prfessinally manage the patient visit when there may be a language barrier? 3. Review understanding f learning bjectives: Practice standard precautins a. Describe the standard precautins yu used while caring fr Mr. Fernandez. 4. Review understanding f learning bjectives: Obtain vital signs a. Review the vital signs yu btained fr Mr. Fernandez. Are these within nrmal limits fr a 62-year-ld male? 5. Review understanding f learning bjectives: Obtain patient histry a. What kind f health histry questins are imprtant t review with a patient with heart failure? 6. Review understanding f learning bjectives: Emply elements f therapeutic cmmunicatin based upn theries f psychlgy a. Did Mr. Fernandez exhibit any cues that indicated yu shuld utilize sme therapeutic cmmunicatin? b. Hw did yu respnd t his cncerns? Was it effective? c. If yu culd d ver while cmmunicating with Patrick, is there anything yu wuld d differently? 7. Review understanding f learning bjectives: Assist physician with patient care: rutine examinatins a. When assisting with patient care f a patient with heart failure, what data is especially imprtant t be btained? 8. Review understanding f learning bjectives: Cach patients regarding: treatment plan HEART FAILURE SIMULATION UPDATED: JULY 25,

15 a. Describe the handut that yu reviewed with a patient with heart failure. What are sme imprtant tpics t emphasize fr self-management f this cnditin? 9. Review understanding f learning bjectives: Perfrm capillary puncture and btain bld glucse reading. a. Evaluate yur explanatin f the bld glucse prcedure t Mr. Fernandez. Hw did it g? b. Evaluate yur perfrmance f the capillary bld glucse prcedure. Is there anything yu wuld d differently if yu culd d ver? 10. Review understanding f learning bjectives: Obtain clean catch midstream urine sample and perfrm urinalysis using reagent strips a. Evaluate yur explanatin f the clean urine catch prcedure t Mr. Fernandez. Hw did it g? If yu culd d ver, wuld yu explain anything in a different manner? b. Why is the clean catch prcedure imprtant fr an accurate sample? c. Explain hw yu evaluated the reagent strip. 11. Summarize/Take Away Pints: a. In this scenari yu assisted in caring fr a Hispanic male patient with chrnic heart failure. Yu perfrmed a capillary bld glucse and btained a clean catch urine sample fr urinalysis. What is ne thing yu learned frm participating in this scenari that yu will take int yur nursing practice? (Ask each student t share smething unique frm what the ther students share.) NOTE: Debriefing technique is based n INASCL Standard fr Debriefing and NLN Thery- Based Debriefing by Dreifuerst. HEART FAILURE SIMULATION UPDATED: JULY 25,

16 SURVEY Print this page and prvide t students. Students, please cmplete a brief (2-3 minute) survey regarding yur experience with this ARISE simulatin. There are tw ptins: 1. Use QR Cde: Survey a. Nte: Yu will need t dwnlad a QR Cde reader/scanner nt yur wn device (smartphne r tablet). There are multiple free scanner apps available fr bth Andrid and Apple devices frm the app stre. b. This QR Cde will nt wrk in the ARIS app. SURVEY 2. Cpy and paste the fllwing survey link int yur brwser: a. HEART FAILURE SIMULATION UPDATED: JULY 25,

17 APPENDIX A: HEART FAILURE PATIENT EDUCATION HANDOUT What Can I D t Manage Heart Failure? Althugh heart failure cannt be cured, it can be managed well. Yur treatment plan may include medicines, surgery, implantable medical devices, r a cmbinatin f these appraches. There are als a lt f things yu can d t help imprve yur cnditin. Tgether with prper medical care and careful mnitring, gd self-care can help yu feel better, stay ut f the hspital, and live a lnger life. T manage yur heart failure, it is best if yu d the fllwing: Take yur medicines regularly as prescribed by yur dctr. When the medicines that yur dctr has prescribed are taken regularly and at the crrect dses, they can make yu feel better, reduce hspitalizatins, and help yu live lnger. Experts in heart failure call many f these medicines lifesaving. Since yur medicatin is very imprtant, when traveling, keep yur medicatin in yur carry-n luggage and bring it with yu n the plane. It is helpful t keep yur medicine rganized, and remember t refill yur prescriptins befre yu travel s that they d nt run ut. Weigh yurself every day and write it dwn. Daily changes in weight are usually the result f water weight. By weighing yurself every day at the same time, yu can help mnitr whether yur bdy is retaining fluid due t heart failure. Even thugh yu may feel the same, a gain f just 3 t 4 punds ver a few days is a sign f wrsening cngestin that must be treated. If treated, yur heart and lungs can functin mre easily and yu may feel mre cmfrtable. If left untreated, it may becme mre serius and require hspitalizatin. Fllw a lw-sdium (lw-salt) diet. Heart failure can cause yur bdy t retain sdium and result in fluid buildup. The extra fluid makes yur heart wrk harder and yur symptms get wrse. HEART FAILURE SIMULATION UPDATED: JULY 25,

18 A lw-sdium diet generally means that yu eat n mre than abut 2,000 milligrams (mg) f sdium per day. That amunt is less than 1 teaspn f salt frm all surces, including the salt that is already in yur fd. T reduce the sdium in yur diet, stp adding additinal salt t yur fd. Avid prcessed fds especially canned, bxed, r bagged fds and eat mre fresh vegetables and fruit. Be sure t review the nutritinal infrmatin labels n all packaged fds fr sdium cntent, and decrease the ttal amunt f salt yu eat per day. Pay clse attentin when eating at restaurants. Many restaurants will tell yu nutritinal infrmatin f fds if yu ask. They will hld salt when cking if yu ask and will serve salad dressing and sauces/gravies n the side. Als pay attentin t certain fds that cntain a large amunt f water, such as head lettuce r watermeln. Althugh fllwing a lw- sdium diet might be a challenge, by fllwing the diet recmmended by yur dctr r nurse yu will gain better cntrl f yur cnditin. Get regular physical activity. Heart failure can make yu feel tired. One f the ways t feel better is t keep physically active thrugh a regular exercise prgram. In general, start slwly and increase yur exercise gradually. Talk t yur dctr abut an exercise prgram that is best fr yu. Exercise can be a highly valuable plan t imprve yur cnditin. Quit smking. Quitting smking is ne f the best things yu can d fr yur heart and verall health. Smking damages yur bld vessels, increases yur bld pressure, and causes lung disease in additin t ther prblems. Quitting smking is strngly recmmended fr all peple with heart disease, including heart failure. Talk t yur dctr r nurse abut new methds fr helping peple quit smking. HEART FAILURE SIMULATION UPDATED: JULY 25,

19 Stay cnnected scially. energy. Yur family and friends can help. Dn t keep yur cnditin a secret. Let yur family and friends supprt yu and help yu stay with yur treatment plan. Having an active scial life can als help keep yur mind ff yur prblems and give yu a mre psitive utlk n life. Participating in activities that yu enjy reminds yu f why yu want t take gd care f yurself and stay healthy. Plan sme fun activities that will reduce stress and give yu Mnitr yur symptms daily and learn when t call yur dctr. Yu knw yur heart failure symptms best. Write dwn when yu ntice yur symptms are getting better r wrse, r when yu develp new symptms. This infrmatin can help alert yu as t when yu shuld call yur dctr and can als help yur dctr make changes t yur treatment. Feel free t ask yur dctr and nurse any questins yu might have abut yur treatment plan. Adapted by the SCA Preventin Medical Advisry Team frm the IMPROVE HF registry tlkit. This material is intended t be educatinal. It is nt intended t replace the infrmatin prvided t yu by yur healthcare prviders and may nt be directly applicable fr yur individual clinical circumstance. Please refer t the manufacturers prescribing infrmatin and/r instructins fr use fr the indicatins, cntraindicatins, warnings, and precautins assciated with the medicatins and devices referenced in these materials. Spnsred by Medtrnic, Inc. May 2007 HEART FAILURE SIMULATION UPDATED: JULY 25,

20 APPENDIX B: PROCEDURE CHECKLISTS PROCEDURE CHECKLISTS OBTAINING CAPILLARY BLOOD GLUCOSE MEASUREMENT USING GLUCOMETER Sanitize hands Assemble equipment Verify expiratin date n cntainer f test strips Calibrate the glucmeter (if needed) Identify patient and explain the prcedure t the patient Ask the patient when the last time smething was eaten and dcument apprpriately Remve a test strip frm the cntainer and immediately replace lid n cntainer Insert test strip int glucmeter Open gauze packet Clean apprpriate anticipated puncture site with antiseptic wipe and allw t dry Apply glves Perfrm a finger puncture at apprpriate site with lancet Dispse f lancet apprpriately Wipe away first drp f bld with a gauze pad Place finger in dependent psitin until a large drp f bld is frmed Apply the drp f bld t target area n the test strip Place gauze ver puncture site and apply pressure Observe digital display f test results HEART FAILURE SIMULATION UPDATED: JULY 25,

21 Remve test strip frm meter and discard apprpriately Check puncture site and apply adhesive bandage, if needed Remve glves and sanitize hands Dcument the test results crrectly Prperly stre the glucmeter CLEAN CATCH MIDSTREAM SPECIMEN COLLECTION INSTRUCTIONS Sanitize hands Identify patient and explain prcedure t patient Label specimen cntainer Instruct male patient t: Wash hands and pen antiseptic twelettes, and remve lid frm specimen cntainer Pull dwn undergarments and stand in frnt f the tilet Retract the freskin f the penis if uncircumcised Cleanse area arund meatus and the urethral pening by wiping each side f the meatus with a separate antiseptic twelette. Use a third twelette t cleanse directly acrss meatus Discard each twelette int tilet after use Vid a small amunt f urine int the tilet Cllect the next amunt f urine by viding int the sterile cntainer withut tuching the side f the cntainer. Fill cntainer apprximately half full with urine. Vid the remaining amunt f urine int the tilet Replace lid n specimen cntainer Wipe area dry with tissue, flush the tilet and wash hands Test specimen r prepare it fr transprt t an utside labratry HEART FAILURE SIMULATION UPDATED: JULY 25,

22 TESTING URINE USING REAGENT STRIP Sanitize hands Assemble equipment Check expiratin date f reagent strips Apply glves Remve reagent strip frm cntainer and recap immediately D nt tuch test areas with fingers Mix the urine specimen thrughly Remve specimen cntainer lid and cmpletely immerse reagent strip in urine Remve the strip immediately and run the edge against the rim f the urine cntainer Hld reagent strip in a hrizntal psitin and place as clse as pssible t the clr blcks n clr chart Read the results at the exact reading times specified n the clr chart Dispse f strip int regular waste cntainer Remve glves and sanitize hands Dcument results accurately. HEART FAILURE SIMULATION UPDATED: JULY 25,

23 CREDITS Heart Failure Patient Educatin handut frm American Heart Assciatin, Get with the Guidelines HF Clinical Tls Library. Dwnladed frm uidelines-hf/get-with-the-guidelines-hf-clinical-tls- Library_UCM_305817_Article.jsp#.WVZ7a03fPIU Medicatin infrmatin frm Natinal Library f Medicine: Daily Med at Image f medicatin bttles frm Picture f edema frm Wikipedia at HEART FAILURE SIMULATION UPDATED: JULY 25,

24 REFERENCES American Heart Assciatin (2016). Get with the Guidelines: Heart Failure. Dwnladed frm With-The-Guidelines---HFStrke_UCM_001099_SubHmePage.jsp Bnewit-West, K., Hunt, S., and Applegate, E. (2013). Tday s Medical Assistant: Clinical and Administrative Prcedures. St. Luis, MO: Elsevier, Inc. Dreifuerst, K.T. (2012). Using debriefing fr meaningful learning t fster develpment f clinical reasning in simulatin. Jurnal f Nursing Educatin, 51(6), di: Internatinal Nursing Assciatin fr Clinical Simulatin and Learning. (2013). Standards f best practice: simulatin. Retrieved frm: Stella, L. (2013). Understanding Measures fr Heart Failure Treatment, American Nurse Tday, 8(2). Dwnladed frm: HEART FAILURE SIMULATION UPDATED: JULY 25,

25 This wrk by the Wiscnsin Technical Cllege System TAACCCT IV Cnsrtium is licensed under a Creative Cmmns Attributin 4.0 Internatinal license. Third party marks and brands are the prperty f their respective hlders. Please respect the cpyright and terms f use n any webpage links that may be included in this dcument. This wrkfrce prduct was funded by a grant awarded by the U.S. Department f Labr s Emplyment and Training Administratin. The prduct was created by the grantee and des nt necessarily reflect the fficial psitin f the U.S. Department f Labr. The U.S. Department f Labr makes n guarantees, warranties, r assurances f any kind, express r implied, with respect t such infrmatin, including any infrmatin n linked sites and including, but nt limited t, accuracy f the infrmatin r its cmpleteness, timeliness, usefulness, adequacy, cntinued availability, r wnership. This is an equal pprtunity prgram. Assistive technlgies are available upn request and include Vice/TTY (771 r ). HEART FAILURE SIMULATION UPDATED: JULY 25,