Download Home Infusion Therapy

Home Care Infusion
Management of Heart
Failure
Margaret Lyons DNP, RN, CRNI
Villanova University / Jefferson Home Infusion Service
Villanova and Philadelphia, Pa.
[email protected]
Incidence & Prevalence
HF or congestive heart failure (CHF) is a disease state that afflicts
approximately 6.6 million U.S. (Roger et. al, 2012)
HF is the preferred term to use as not all patients with this disorder
experience fluid accumulation or congestion. (Rosa, 2008)
Each year, 670,000 patients are newly diagnosed with the disease.
(CDC, n.d.)
More common in African American and Hispanic males. (Roger et.al, 2012)
Dominates in the elderly – 11% over 80 years. (Iyngkaran, et. al 2015)
Risk Factors
Major Clinical Risk Factors
• Age, male gender
• Hypertension, LVH
• Myocardial infarction
• Diabetes mellitus
• Valvular heart disease
• Obesity
Toxic Risk Precipitants
• Some Chemotherapies
• Cocaine
• NSAIDs
• Alcohol
Genetic Risk Predictors
• SNP (e.g., 2CDel322-325, 1Arg389)
Morphologic Risk Predictors
• Increased LVID, mass
• Asymptomatic LV dysfunction
• LV diastolic dysfunction
Minor Clinical Risk Factors
• Smoking
• Dyslipidemia
• Sleep-disordered breathing
• Chronic kidney disease
• Albuminuria
• Homocysteine
• Immune activation, IGF1, TNF, IL-6, CRP
• Natriuretic peptides
• Anemia
• Dietary risk factors
• Increased HR
• Sedentary lifestyle
• Low socioeconomic status
• Psychological stress
Schocken D. D., Benjamin, E., Fonarow, G.
C., Krumholz, H. M., Levy, D., Mensah, G. A.
(2008). Functional Genomics and
Translational Biology Interdisciplinary
Working Group.
Diagnosis / Functional Classification
Diagnosis:
–
–
–
–
–
+ H+P with symptomatology
↑Type B natriuretic peptide (BNP) or
↑N-terminal pro b-type natriuretic peptide (NTproBNP) levels
Elevated cardiac troponin
LVEF levels ≤35%
(HFSA, 2010; NICE, 2010; Jessup et al., 2009)
Classifications:
New York Heart Association’s (NYHA) method is generally used to classify function.
American College of Cardiology (ACC) / American Heart Association’s (AHA)
system is used for staging.
Patients in NYHA Class IV (severe) and ACC/AHA stage D (refractory) could
be candidates for inotropic therapy (HFSA, 2010).
New York Heart Association (NYHA)
Classification
• Class I (mild): Diagnosis of HF is made but patient experiences minimal
symptoms. Focus of treatment is on regular exercise, limiting alcohol
consumption, and eating healthy with moderate sodium intake.
Hypertension if present is treated and smoking cessation is crucial.
• Class II (mild): Patients exhibit symptoms with physical activity like
bending over or walking. Medications like ACE-inhibitors or betablockers may be considered.
• Class III (moderate): Patients experience limitations (fatigue and
shortness of breath) during physical activity but are usually comfortable
at rest. HCP should monitor diet and exercise and diuretics may be
prescribed.
• Class IV (severe): Patients cannot exert themselves and show
significant signs of cardiac problems even while resting. Surgical options
will be explored.
American College of Cardiology (ACC) /
American Heart Association (AHA) Staging
Stage A (High Risk): No symptomatology but have several of the risk factors for HF
development (obesity, highfat or sodium diet, smoking, alcohol intake, drug use or
abuse, and lack of physical exercise, diabetes, infection, advanced age, or family
history.
Stage B (Asymptomatic): Diagnosis of HF but not experiencing symptoms. Healthcare
providers will be monitoring or treating underlying causal process like HTN and may be
prescribed an ACE inhibitor or beta-blocker.
Stage C (Symptomatic): Cardiac dysfunction is present with symptomatology like
fatigue and shortness of breath. Attention should be paid to supervised exercise,
healthy diet with low sodium intake, and little to no alcohol consumption.
Stage D (Refractory/End Stage): Signs and symptoms of HF persists after treatment
and therapy. Monitoring of diet, exercise, and blood pressure are still adhered to and
patients will probably be prescribed medications and can include surgical options
(depending on severity) such as a conventional pacemaker, a ventricular device such
as a BiV pacemaker, LVR surgery, or heart transplantation.
Prognosis
The associated morbidity and mortality is high.
One of five people will not be alive one year
from the date of diagnosis (CDC, n.d.).
Half of all patients diagnosed with HF will die
within five years (Roger et al., 2012).
End stage HF has limited treatment options.
Patient Assessment
Symptoms
*Shortness of breath (SOB)
Orthopnea
Paroxysmal nocturnal dyspnea
(PND)
*Generalized fatigue
Weakness and exercise
intolerance
*Study by Kato et al. (2012)
worst symptoms reported by
patients.
Additional Symptoms:
*Fluid retention, with possible
weight gain and swelling of the
feet, ankles, or abdomen.
Jugular venous distention (JVD)
and hepatomegaly.
S3 (ventricular gallop) (cardinal
sign in older adults)
S4 (atrial gallop)
HX myocardial infarction (MI),
chronic HTN or Aortic stenosis
(AS)
Jack - Heart Failure Client
History – Obesity, HTN, MI, Depression, CVA post cardiac
catheterization (no neurological deficits),, Asthma / COPD,
Chronic Renal Insufficiency and Prostate Cancer
Effective Management is Key
HF’s course is characterized by frequent exacerbations and periods of
control.
Center for Medicare & Medicaid Services (CMS) mandates will not cover
hospital and home care costs for a patient readmitted within 30 days of a
discharge where HF was the admitting diagnosis. (Stone & Hoffman, 2010)
Penalties for readmissions have been authorized by the Hospital
Readmission Reduction Program began in 2013. (Stone & Hoffman, 2010)
Private health care insurers are considering reimbursement penalties similar
to those of CMS, making managing HF in a manner that decreases
recidivism highly relevant. (Sommers & Cunningham, 2011)
HF management in the home is less costly than routine hospital
care. (Frick, Burton, Clark et al. 2009)
Home Infusion Therapy: Twofold Bridge
“Bridge to transplant” in adults and children and as a way
to manage advanced HF until end of life.
Types of Home Therapies
Lifestyle Modification
Oral medications
Implanted Devices




Pacemakers
Defibrillators
Chronic Resynchronization Therapy (CRT)
Left ventricular assistive devices (LVADs)
IV Medications and Infusion
 Furosemide
 Inotropes – Dopamine, *Dobutamine and
*Milrinone (*more common in home)
Furosemide
Indications
•Edema due to heart failure, hepatic impairment or renal disease.
•Hypertension.
Action
•Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal
tubule.
•Increases renal excretion of water, sodium, chloride, magnesium, potassium, and
calcium.
•Effectiveness persists in impaired renal function.
Half – life - 30–60 min (↑ in renal impairment)
Dosage
•IM: IV: (Adults) 20–40 mg, may repeat in 1–2 hr and ↑ by 20 mg every 1–2 hr until
response is obtained, maintenance dose may be given q 6–12 hr; Continuous infusion–
Bolus 0.1 mg/kg followed by 0.1 mg/kg/hr, double q 2 hr to a maximum of 0.4 mg/kg/hr.
•IM: IV: Children 1–2 mg/kg/dose q 6–12 hr Continuous infusion– 0.05 mg/kg/hr, titrate
to clinical effect.
http://www.drugguide.com/ddo/view/Davis-Drug-Guide/51345/all/furosemide
Most Common Home Inotropes
(Lyons & Carey, 2013)
Treatment Guidelines
National Institute for Health and Clinical Excellence (NICE)
Heart Failure Society of America (HFSA)
American College of Cardiology Foundation (ACC) and the American Heart Association
(AHA)
The ACCF/AHA guidelines (2009) state that “the decision to continue intravenous
infusions at home should not be made until all alternative attempts to achieve stability
have failed repeatedly, because such an approach can present a major burden to the
family and health services and may ultimately increase the risk of death” (p. 1362).
Therefore, clinical judgment and collaboration with the patient regarding all possible
treatment options is paramount to deliver Guideline Directed Medical Therapy (GDMT).
Intermittent infusion not supported by ACC / AHA. Use of continuous Inotropes is not
preferred if patient is candidate for Mechanical Circulatory Support or Transplantation
as morbidity with use is high (2013).
Management of Home Infusion
Therapies for HF (ADOPIE)
• Assessment
• Nursing Diagnosis of pertinent issue(s)
• Outcome Planning (care based on
self-care approach)
• Implementing interventions
• Evaluation (client condition / need for
additional referrals for further
interventions)
Role of the Infusion Nurse
• Discharge Planning
• Working with reimbursement personnel
• Collaborating to choose an appropriate access
device for client
• Care and maintenance of access device
• Patient Education (crucial) includes: explanation
of disease, symptoms to report and behaviors to
help modify exacerbations, IV medication
administration of medication to client / caregiver.
Discharge Planning
Gorski’s 7 Key Questions to Address
1) Is the patient willing and able to participate in the home
infusion therapy (HIT)?
2) Is the patient clinically stable, and has the HIT plan been
identified?
3) Is a caregiver required at home during infusions?
4) Is the infusion access device appropriate for home care?
5) Can the patient’s therapy be interrupted during the
transportation from hospital to home?
6) Are there any home environmental issues?
7) Is there appropriate reimbursement for home care?
(Gorski, 2005)
Access Device
• Need true central line (meds are vesicant)
Unless client only needs intermittent furosemide could
have a peripheral IV.
• PICC or Implanted Port with tip ending in Right
Atria or lower third of SVC
• If PICC – 2 lumens in case
of occlusion.
Reimbursement Issues
• Milrinone more $$$ than Dobutamine but not as
expensive as readmission.
• Some insurance companies want extensive
testing prior to authorization which may or may
not have been completed during stay i. e.
hemodynamic cardiac monitoring to show that
inotrope improved Cardiac Index (CI) and
Pulmonary Capillary Wedge Pressures (PCWP).
• Sometimes documented symptom improvement
will suffice.
Client Education / Nurse Education
Lifestyle Management
• Diet (Na and fluid restrictions)
• Weight loss
• Smoking cessation
• Oral medication use (diuretics)
Symptoms to Report
(can use tele-monitoring or apps -if
available and patient is interested in
using)
– Daily weights, BP (hypotension),
edema, SOB and orthopnea
IV Administration
• Back up pump and spare med
• No flushing to avoid bolus
• Storage of meds and supplies
• Visit frequency to expect RN
• Inotrope dependency
Nurse Competencies
• CVC / PICC dressings
• Phlebotomy
• Peripheral IV insertion
• Dose per minute calc / volume per
hour calculation
• JVP estimations
(www://wn.com/jugular_venous_diste
nsion_example)
• Inotrope and beta blockers (MOA)
• Creatinine monitoring
• Vesicant nature of drug
• Central line infection monitoring
• Motivational Interviewing (MI)
E-Health Technologies
7 in 10 (69%) US adults track a health indicator for themselves or a loved
one.
(Iyngkaran, et al., 2015)
Patient Examples
Clinician Examples
Activity monitoring
(Fitbit, Jawbone, NikeFuel)
Diet apps
(myfitness Pal, Fatsecrets)
Sleep tracking
(sleep bug)
Physiological monitoring devices
•
HR
Electronic Health Records (EHR)
(ehealth.gov, WellnessFX, Epic)
–
•
•
(Aria, iHealth)
BP
–
•
(Polar, Mio, Pulseon)
Wireless Scales
–
(iHealth)
Data from Internal Devices
–
Clinical Decision Support Systems
Self reported data from pt apps & EHR
Apple HealthKit,
Google Fit platforms
Microsoft Healthvault
From manufacturer
Peer support
(patientslikeme, healthshare)
Online Ways to provide Feedback to Patients
Email, Health portals
Video conferencing , SKYPE
Teaching Medication Administration
• Caregiver required.
• Pump use – alarms and setting up
infusion, need for spare pump and
medication bag in case of malfunction.
• When to call RN – occlusion, redness or
swelling of PICC / CVP, trouble with
infusion, change in status – weight,
SOB etc.
Outcomes / Risks
• Improved symptomatology
• Increased functional status
• Increased hemodynamic
function
• Decreased hospital
admissions
• Decreased length of stay
when hospitalized
• Allows for patients to remain
home with loved ones
(especially critical to
pediatric patients awaiting
transplant)
• Cost effective
• Potential line infection
• Potential development of
arrhythmias
– Many clients have implanted
defibrillators
• Potential hypotension
• Potential for sudden death
• High mortality rates
Barriers to Successful Treatment
• Geography, staffing, health literacy,
depression, cognitive impairment, low
self-confidence, age, culture, comorbidities, lower socioeconomic status
and lifestyle factors.
Future Heart Failure Therapies
• New pharmaceutical options
– Natriuretic peptides, calcium sensitizers, sarcolemmal
calcium receptor or Na–K ATPase agents, free fatty acid
metabolism modulators, and cardiac myosin activators
• Improved availability of donor organs
• More sophisticated mechanical devices such as
heart pumps
• Stem cell therapy
• Gene therapies
– CUPID trial
References
Assad-Kottner, C., Chen, D., Jahanyar, J., Cordova, F., Summers, N., Loebe, M., ... & Torre-Amione, G. (2008). The Use of Continuous Milrinone
Therapy as Bridge to Transplant Is Safe in Patients with Short Waiting Times. Journal of Cardiac Failure, 14(10), 839-843. doi:
10.1016/j.cardfail.2008.08.004
Centers for Disease Control and Prevention [CDC]. (n.d.). Heart Failure Fact Sheet. Retrieved from
http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_heart_failure.htm
The Criteria Committee of the New York Heart Association (NYHA). (1994). Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great
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Percutaneous Administration of Gene Therapy in Cardiac Disease (CUPID Trial), a First-in-Human Phase 1/2 Clinical Trial. Journal of
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