Target Weight at the Center of Heart Failure. April 24, 2018

Transcription

1 Target Weight at the Center of Heart Failure April 24, 2018

2 Disclosures None 2

3 Our Mission and Vision 3

4 Acute Heart Failure Gradual or rapid change in HF symptoms resulting in a need for urgent therapy ~ 1.0 million annual hospitalizations for HF in US Cost estimates: > $20 billion Projected > $50 billion by % of costs: hospitalizations

5 Heart Failure in the MHACO April 2016 March 2017 MHACO # chronic HF 8713 Deaths 10.6% Hospitalizations/1000 beneficiaries 708 Readmissions (30 day)/1000 discharges 166

6 What are acute HF care goals? Early diagnosis Early relief of symptoms Identify cause Triage consistently Integration with inpatient and/or post-acute care

7 What is a Target Weight? Target weight is the weight at which the patient has achieved intravascular euvolemia - Euvolemia is defined as wedge of </=15 - Wedge pressure is roughly twice the CVP - Diurese to CVP of 5-8 as a goal and use that weight as a target weight - If exam findings are uncertain, perform right heart catheterization

8 Intracardiac Pressures

9 Why do we call it Target Weight?

10 The Target Weight Goal weight, ideal weight, healthy weight, dry weight The weight at which the patient is stable on appropriate medications - Established using varying levels of assessment» Hospital/clinic/provider office» SNF or home health» Cardiac rehab - Must be translated from scale to scale!

11 Why do we care? Decongesting heart failure patients: - Improves quality of life - Correlated with improved survival in the treatment of decompensated heart failure

12 Volume status predicts mortality and morbidity in heart failure patients 1. Stevenson et al. Am J Card 1990;66(19): Cooper et al. J Card Fail 2016;22(3): Androne et al. Am J Card 2004; 93: Gheorghiade et al. JACC 2013; 61 (4):

13 So how do we set it? Exam - Jugular Venous Distention - Peripheral Edema - Rales - Echocardiographic reading of IVC - Right heart catheterization

14 Methods to assess volume status Method Studies (References) Change in weight Gyllensten et al. JMIR Med Inform. 2016; 4(1): e3. Physical exam findings Stevenson et al. JAMA 1989; 261(6): Reliability of physical examination skills Davison et al. Am Heart J 1974; 87(3): Brennan et al. Am Heart J 2007; 99(11): Demeria et al. Chest 2004; Abstract 747S. Sinisalo et al. Am J Card 2007; 100(12): Chest X-ray Blood volume analysis BNP/proNT-BNP Intrathoracic impedance CardioMEMS This is essentially a permanent right heart catheterization (gold standard)

15 Target Weight Serves as the basis for - Ongoing diuretic management - Patient self-management - SNF Heart Failure Protocol - Home Diuretic Protocol Home Health - Emergency Room management

16 Risk Acute Decompensated Heart Failure Emergency Medical Services Risk stratify: nl renal function, Trop, BP Early Intervention to decongest Inpatient Service Precision Medicine Part 1: Refine Dx, Rx, Educate interventions Outpatient Service Patient Centered, Coordinated Care Wellness

17 Breaking the Cycle of Readmission *Follow up within 7-10 days *Telephone F/U within 24 hours *Disease Management referral *Home Health Admission *Assessment to prepare for discharge *Reason for admission addressed *Medication reconciliation *JCAHO Core Measures *Patient/caregiver education *Follow up appointment scheduled *Able to fill prescriptions Follow up Hospital Discharge Transitional Care Hospitalization and Treatment Discharge Planning *Adequate diuresis *EBT Home Health Care/SNF Social support DME for home care

18 Tools to Assist in Care Coordination MaineHealth Heart Failure Toolkit: - Strategies and tools available in different areas in the health care system to support the treatment of heart failure patients - For the patient:

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25 Tools to Assist in Care Coordination MaineHealth Heart Failure Toolkit: - Strategies and tools available in different areas in the health care system to support the treatment of heart failure patients - For different patient areas:

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29 Tools to Assist in Care Coordination MaineHealth Heart Failure Toolkit: - Strategies and tools available in different areas in the health care system to support the treatment of heart failure patients - For medical staff:

30 Current Inpatient HF Order Set Specialty OS used in conjunction with Gen Med Adult Admission OS Revised to be stand-alone OS Add guidance on» Provide clearer guidance better aligned to needs of HF patient and eliminate redundancy Target Weight Iron levels & supplementation Revised dietary guidance Palliative care referral, surprise question Cardiac Rehab referral Care Management referral Home Diuretic Protocol referral 30

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33 SeHR System Update Effective Date: Currently Available Role: Clinical Users New Lifestyle Activity!! (CHF Target Weight is found here) An Activity Opens with two sections, Lifestyle-Healthy Habits & Cardiology Lifestyle-Healthy Habits This sections follows the MaineHealth Healthy Habits guidelines. Document the patient s rest, fluid intake, eating, and physical activity habits. Click on New Reading to record data. 33

34 SeHR System Update 34

35 SeHR System Update 35

36 SeHR System Update 36

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38 SeHR System Update 38

39 Healing Hearts Discharge SmartPhrase, Proposed.HHINSTRUCTIONS My Diagnosis: *** Today's Weight: *** Target Weight: *** Today's Resting Heart Rate: *** Target Resting Heart Rate: *** Today's Blood Pressure *** Target Blood Pressure: *** If my weight goes up or down 4 pounds and/or my swelling, breathing or energy level gets worse, I need to call: *** 39

40 A Mandate The ACC/AHA HF Guidelines

41 A Mandate The ACC/AHA HF Guidelines

42 A Mandate The ACC/AHA HF Guidelines

43 Heart Failure Disease Management Program Medical experience/knowledge Dedicated multi-disciplinary specialist team: - Heart failure trained cardiologists - Heart failure certified nurses - Dedicated social worker, chaplain, palliative care specialist, etc. Streamlined process for inpatient, outpatient, and transitions of care Accessible for referrals/questions/communication System can be adopted by another institution

44 MH SNF Protocol Plan is to educate the nurses, daily weights, adjusting diuretics, education for the patients prior to discharge. Home health diuretic protocol. The 4 pathways: ED, inpatient, SNF, home health. Increased satisfaction in CNAs and nurses. Currently gathering data on outcomes. 44

45 Left Ventricular Assist Device HeartMate II Axial Rotary Pump HeartWare HVAD Centrifugal Rotary Pump

46 Heartmate III - Heartmate III, Centrifugal Rotary Pump

47 Cardiomems

48 Cardiomems

49 Transplant Shared Care

50 Acknowledgements HF team EPIC team Administrative team Service line team

51 System-wide heart failure management Thank you! Let us know how to help!