CHF flowsheet and the CDM toolkit Guideline based care The following are taken from the GPAC Guidelines : Heart Failure Care (Feb 15, 2008) Main indicators on the flowsheet for use in office practices several available, (2 on the toolkit) Diagnosis of Heart Failure (adapted from CTS guidelines) Systolic Heart Failure Systolic heart failure: The pumping action of the heart is reduced or weakened. A common clinical measurement is the ejection fraction (EF). The ejection fraction is a calculation of how much blood is ejected out of the left ventricle (stroke volume), divided by the maximum volume remaining in the left ventricle at the end of diastole or relaxation phase. A normal ejection fraction is greater than 50%. Systolic heart failure has a decreased ejection fraction of less than 50%. Diastolic heart Failure Diastolic heart failure: The heart can contract normally but is stiff, or less compliant, when it is relaxing and filling with blood. This impedes blood filling into the heart and produces backup into the lungs and CHF symptoms. Diastolic heart failure is more common in patients older than 75 years, especially in women with high blood pressure. In diastolic heart failure, the ejection fraction is normal. Diastolic Heart failure Diastolic heart failure, a major cause of morbidity and mortality, is defined as symptoms of heart failure in a patient with preserved left ventricular function. It is characterized by a stiff left ventricle with decreased compliance and impaired relaxation, which leads to increased end diastolic pressure. Signs and symptoms are similar to those of heart failure with systolic dysfunction. The diagnosis of diastolic heart failure is best made with Doppler echocardiography. Diastolic Heart failure Based on current knowledge, pharmacologic treatment of diastolic heart failure should focus on normalizing blood pressure, promoting regression of left ventricular hypertrophy, avoiding tachycardia, treating symptoms of congestion, and maintaining normal atrial contraction when possible. Diuretic therapy is the mainstay of treatment for preventing pulmonary congestion, while beta blockers appear to be useful in preventing tachycardia and thereby prolonging left ventricular diastolic filling time. Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers may be beneficial in patients with diastolic dysfunction, especially those with hypertension Heart failure Heart failure affects 1% of people aged 50 years, about 5% of those aged 75 years or older, and 25% of those aged 85 years or older. Heart failure is the most common reason for Medicare patients to be admitted to the hospital. As the number of elderly people continues to rise, the number of people diagnosed with this condition will continue to increase. In the United States, nearly 5 million people have heart failure. Each year about 550,000 new cases are diagnosed. The condition is more common among African Americans than whites. The rate of death from heart failure is about 10% after 1 year. About half of those with CHF die within 5 years after their diagnosis. These statistics vary widely by a patient's exact diagnosis and therapy. Advances in research are providing more options and improving outcomes for people with CHF. Management Drug Therapy for Systolic HF (EF < 40%) Diuretics Monitoring Diuretics… Beta-Blockers (BB) Beta blockers Equivalent Doses Ace Inhibitors ACE inhibitors are the most widely used vasodilators for CHF. They block the production of angiotensin II, which is abnormally high in congestive heart failure. Angiotensin II causes vasoconstriction with increased workload on the left ventricle, and it is directly toxic to the left ventricle at excessive levels. ACE inhibitors are important because they not only improve symptoms, but they also have been proven to significantly prolong the lives of people with heart failure. They do this by slowing progression of the heart damage and in some cases improving heart muscle function. Some common examples of ACE inhibitors are captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril/Prinivil), benazepril (Lotensin), quinapril (Accupril), fosinopril (Monopril), and ramipril (Altace). ACE-Inhibitors (ACE-I) ACE-Inhibitors (ACE-I)-Side-Effects ARBS Angiotensin II receptor blockers (ARBs) work by preventing the effect of angiotensin II at the tissue level. Examples of ARB medications include candesartan (Atacand), irbesartan (Avapro), olmesartan (Benicar), losartan (Cozaar), valsartan (Diovan), telmisartan (Micardis), and eprosartan (Teveten). These medications are usually prescribed for people who cannot take ACE inhibitors because of side effects. Both are effective, but ACE inhibitors have been used longer with a greater number of clinical trial data and patient information. Angiotensin Receptor Blockers (ARBs) Direct-Acting Vasodilators Spironolactone Self-management HF care depends on the patients understanding of, and participation in, optimal care. Patients can be important partners in individualized goal setting, salt restriction, weight monitoring and adherence Self-monitoring Weight Salt intake Fluid intake Alcohol Exercise Training Immunization Collaboration with other health care partners A few Patient Resources to aid with Self-management… GPAC….. • Patient handout and reminders… (examples on the following pages) Impact BC www.impactbc.ca/collaboratives/congestiveheartfailure/resources Examples… Personal Action Plan - Burnaby Hospital Patient Teaching Log Resources for People with Heart Failure - A Guide for Patients IRRP Datasheet Cardiology Consult Form Patient Education Record End of Life Choices Care of Heart Failure in Adults: Summary Add any comments Here Flowsheet and CDM toolkit- Implementing the flowsheet From two perspectives… GP MOA A few words on why enter the data onto the Toolkit? The benefits… Monthly recall reports Using the search to find specific details • (advanced search) • (key measures) Using the run charts to monitor changes Usefulness hinges on… Complete and accurate data entry Navigating the Toolkit and understanding nuances Spending the time Steps to success… 1. Understanding the flowsheet indicators 2. Creating an office system • Coding files (color), requisitions… • Flagging patients who need a flowsheet… • Calling patients in for recall… 2. Consistent entering • Allowing MOA sufficient entering time 3. Reflection • Take some time to look at your data critically Understanding the Flowsheet Key indicators CHF: PSP goals and measures 50% Of patients are on ACE/ARB and BB 80% Of patients are on ACE/ARB 80% Of patients are on BB 70% Of patients will have a self-management goal documented annually Creating your own office systems… Use your colleagues Test them (use the PDSA model if you can) Write them down once a protocol has been established Making Time to see results… Setting aside designated time for data entry and reconnecting… •Monday at 3pm at back office desk to CHF flowsheet data entry. Why???? Seems like a waste of time??? Creates a situation where the data becomes valuable in understanding your patient population Means finding patients who are “slipping through the cracks” Using your Reports…. Examples…Recall Key Measures Run charts Advanced searches ACE-I Indicator should be included on the flowsheet if any Ace-I at any dose prescribed within the last 12 m. ARB Indicator should be included on the flowsheet if any ARB any dose prescribed within the last 12 m. Beta-Blockers Indicator should be included on the flowsheet if any dose of the following have been prescribed within the last 12 m…. Carvedilol Metoprolol tartrate Metoprolol succinate Bisoprolol Self-Management Only check this field if an SM goal-setting visit has occurred. Note that this visit requires a discussion with setting patient- specific goals – not simply patient education about CHF.
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