Heart Failure, Anticoagulants, and Medication Reconciliation

Transcription

1 Change in Condition: Heart Failure, Anticoagulants, and Medication Reconciliation Lindsay Holland, MHA Director, Care Transitions Health Services Advisory Group (HSAG) Pouya Afshar, MD, MBA Hospitalist, SNFist, Transitionalist CMO, Integrated Healthcare Alliance, San Diego April 25, 2018

2 How to Submit a Question 1. To submit a question, click on the Chat option at the top right of the presentation. 2. The Chat panel will open. 3. Indicate that you want to send a question to All Panelists. 4. Type your question in the box at the bottom of the panel. 5. Click on Send. To connect to the audio portion of the webinar, please have WebEx call you. 2

3 Change in Condition: Heart Failure, Anticoagulants, and Medication Reconciliation Lindsay Holland, MHA Director, Care Transitions Health Services Advisory Group (HSAG) Pouya Afshar, MD, MBA Hospitalist, SNFist, Transitionalist CMO, Integrated Healthcare Alliance, San Diego April 25, 2018

4 Heart Failure Inability of the heart to pump adequate blood to meet metabolic requirements of tissue Systolic failure (HFrEF) - decreased contractility (EF < 40%) - left ventricle (LV) dysfunction Diastolic failure (HFpEF) - decreased filling (EF > 50%) Mixed 4

5 Prevalence 5.5 million Americans 500,000 new cases/year $25 50 billion/year 300,000 deaths/year > 50% CHF discharges to SNF * expire in < 1 year > 30% CHF discharges to home expire in < 1 year Most common cause for hospitalization in patients > 65 years 25% readmission 30 days 50% readmission 90 days 5 *Skilled nursing facility (SNF)

6 Etiology HTN * Ischemic heart disease (peripheral vascular disease) Valvular heart disease Arrhythmias Viral Toxins Obesity Anemia Sleep apnea 6 *Hypertension (HTN)

7 3 Treatment Groups in SNFs Mild/Subacute CHF * treat in SNF - O 2 sat > 85% RA or 90% w/o 2 - RR < 25 - SBP > 100, < 180 Severe/Acute CHF transfer to hospital - O 2 sat < 85% RA, unable to maintain O2 > 90% w/o 2 - RR < 10 or >30 - SBP < chest pain Palliative Care treat in SNF 7 *Congestive heart failure (CHF)

8 Palliative Care Establish goals of care, consider DNR/palliative care in patients with: NYHA class 3/4 Frequent hospitalizations Recurrent ICD firing Refractory angina Poor functional status Cachexia 8

9 SNF Management of Heart Failure Nursing education Proper bedside assessment Document admission weight daily weights (3 lbs./day or 5 lbs./week) Medication reconciliation Dietary needs - 3g Na/day or less if symptomatic - Fluid restriction to L/day 9

10 Nursing Communication Physician wish list: What is the problem? What do you need me to do? When do I need to respond? Successful delivery of a sales pitch: Loss of attention/credibility if unable to get to the point in < 10 seconds 10

11 SBAR = SOAP * for Nurses 60 second communication tool: Situation (10 seconds) Background (20 seconds) Assessment (20 seconds) Recommendation (10 seconds) 11 *Subjective Objective Assessment Plan (SOAP)

12 Situation: The Problem Proper identification - name of nurse calling - name of facility - name of patient Chief complaint patient John Smith has signs of worsening heart failure 12

13 Background: The Context Age Code status Type of heart failure Reason for hospitalization and date of discharge Other relevant medical history Current weight vs. admission weight Adherence to medications, diet, fluid restriction 13

14 Assessment: Analysis Symptoms (SOB/DOE, * edema, fatigue, confusion) Onset, severity Physical assessment (vitals, JVD, ** edema, urine output) Medications (dosage of diuretics, adherence) Analysis: Patient is having a CHF exacerbation in setting of medication/dietary non-compliance 14 * Shortness of breath (SOB)/dyspnea on exertion (DOE) **Jugular vein distention (JVD)

15 Recommendation: The Plan Increase diuretics Frequent vitals Labs Dietary consult Goals of care Palliative/hospice consult Update patient/family Proper sign-out to upcoming nurses 15

16 16 Jurgens CY, Goodlin S, Dolansky M, et al. Heart Failure Management in Skilled Nursing Facilities: A Scientific Statement From the American Heart Association and the Heart Failure Society of America Available at Accesses on April 25, 2018

17 Guideline-Directed Medical Therapy (GDMT) Diuretics - loop diuretics (furosemide, bumetanide, torsemide) - thiazides (HCTZ, metolazone) - metolazone: powerful diuretic, QOD dosing, monitor labs ACE-inhibitor/Angiotensin Receptor Blocker (ACE-i/ARB) - ACE-i first line - ARB for patients intolerant of ACE-i (angioedema) - avoid taking ACE-i and ARB together Beta-blockers - Carvedilol, Metoprolol (ER), Bisoprolol Low dose aspirin Statin 17

18 Medication Management: Others Angiotensin receptor-neprilysin inhibitor (EF < 35%) - sacubitril-valsartan Mineralocorticoid receptor antagonist (MRA) Digoxin - spironolactone, eplrenone - maintain concentrations between 0.5 and 0.8 ng/ml Hydralazine plus nitrate - patients unable to tolerate ACE-i/ARB (hyperkalemia) - hydralazine 25mg TID + isosorbide dinitrate 20mg TID 18

19 Medication Complications Drug induced CHF exacerbation a common occurrence via: - sodium retention - negative inotropic effect - direct cardiotoxicity Drug metabolism altered during CHF exacerbation (coumadin, digoxin) Drugs to avoid/use with caution: - NSAIDs (renal impairment/impaired ACE-i response) - Bacrtrim + ACE-i/ARB hyperkalemia - Thiazolidinediones fluid retention - Metformin lactic acidosis - PDE inhibitors cilostazol (FDA contraindication) 19

20 Antithrombotic Therapy Increased risk of stroke/thromboembolic events in HF No major consensus Dr. Hirsch Mehta, MD, FACC There are no set guidelines. People basically do whatever they want for antithrombotic therapy in heart failure. Follow guidelines for Afib (CHADS) or CAD Prior thromboembolic event anticoagulant 20

21 Acute Heart Failure Management in the SNF Diagnostics - CXR - EKG - CMP/CBC - BNP/pro-BNP - Echocardiogram Diuretics Supplemental oxygen Vasodilators (hypertensive patient) Continue with ACE-i/ARB, beta-blocker (with holding parameters) Do not start beta-blocker or ACE-i/ARB during acute exacerbation 21

22 Reduce Readmissions Sign up Today Complete commitment agreement: California Arizona Ohio 22

23 Nursing Home Readmission Assessment Work with your Reducing Readmissions Committee to complete the readmission assessment Focused on operational processes Pre-admission Admission/transfer from hospital Submit completed form online or scan and to your state contact:

24 Register Now for Upcoming Webinars COACHING CALL RRPP Coaching Call Tuesday, May 1, noon PT INTERVENTION STRATEGIES Running a Readmission Review Committee Wednesday, May 23, a.m. 12 noon PT 24

25 25 Questions?

26 Thank you! Lindsay Holland, MHA HSAG Pouya Afshar, MD, MBA Integrated Healthcare Alliance, San Diego 26

27 Continuing Education For continuing education credit (1), please complete the evaluation at: If you registered online for this event, you will also receive the link via . A recording of today s session will be available at: (Click on today s event date to access the recording link) 27

28 28 This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. QN-11SOW-C