CHF Flowsheet and the CDM Toolki by fjhuangjun

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									CHF flowsheet and
 the CDM toolkit
Guideline based care
   The following are taken from the GPAC
    Guidelines : Heart Failure Care (Feb 15,
   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
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.
Drug Therapy for Systolic HF (EF < 40%)
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
   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
   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

   GPAC…..
     • Patient handout and reminders… (examples
        on the following pages)
   Impact BC

  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

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    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
 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

   Use your colleagues
   Test them (use the PDSA model if you can)
   Write them down once a protocol has been
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
   Means finding patients who are “slipping
    through the cracks”
 Using your Reports….
Examples…Recall Key Measures Run charts Advanced searches

        Indicator should be included
        on the flowsheet if any Ace-I
        at any dose prescribed
        within the last 12 m.

      Indicator should be included
      on the flowsheet if any ARB
      any dose prescribed within
      the last 12 m.

                Indicator should be included on the
                flowsheet if any dose of the
                following have been prescribed
                within the last 12 m….
                Metoprolol tartrate
                Metoprolol succinate

                  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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