The Role Of The Heart Failure Specialist Nurses - Case Study Example

Care of Heart Failure in an Older Patient Social, Political, Economic Impact A Case Study Introduction In a study of heart failure specialist services on patient populations, a paper by George Lyratzopoulos et al (2004) explored the potential impact of re-admissions and mortality on these services. It was determined in the study that the potential benefit of specialist services for such patients could "help prevent or postpone approximately four times as many readmissions and at least twice as many deaths" (Lyratzopoulos, Conclusion). An effort will be made to analyse on a personal level the social, political and economic impact of heart failure in the UK. Because it has been determined that congestive heart failure is a chronic disease that requires ongoing care, an effort will be made to research developing literature written on this subject to show how the Government as well as prescription service providers, general practitioners, biotechnologists, and those involved in social work have addressed this problem. The focus will be on the need for heart failure specialist nurses in the community and how they can improve health care in the UK. Patient History The 80-year-old female patient I have chosen to discuss here appears to fit the overall criteria for the above study, which was mainly focused on previously hospitalized patients with interventions through specialist heart failure services in the community. My client was diagnosed with heart failure two years ago and had one additional admission to hospital about one year ago for exacerbation of her heart failure. She felt she had not been given adequate information on her condition. She was referred to community heart failure nurses for education, management and titration of Carvedilol 6.25mg bd. Other heart failure medication prescribed included furosemide 80mg mane, spironolactone 25mg mane and ramipril 5mg bd. The spironolactone was stopped due to increased potassium, urea and creatnine, a decision based on the RALES study (2003). After another admission for chest infection, she was discharged without furosemide, and I was assigned as a community heart failure nurse. She was concerned about having her furosemide discontinued, and it was recommenced after I contacted the physician. The client feels more secure knowing she has someone to contact rather than "bothering" her doctor, and we have developed a good rapport. I am working with her on pharmacology issues, making sure she is responding well to her medications as well as taking the right medications. Heart Failure - Major Health Problem Heart failure has continued to be an escalating public health problem. Chronic heart failure is the "syndrome of breathlessness, fatigue and fluid retention resulting in impaired ability of the heart to pump properly" (Sanderson, 1994, par. 1), often following a heart attack. By the end of the 1990s, 5% of all medical admissions to hospital in UK were related to chronic, or congestive, heart failure (Bosson, 1997). The Department of Health considers it a major concern because there is no cure at present. It therefore has a dramatic effect on the quality of life, and if not properly managed in the community it can also place very heavy pressures on hospital beds through emergency admissions and re-admissions (DOH, 2003). Local GPs in a 2005 clinical audit who had access to a specialist CHF nurse considered the service far more important than did the GPs without a specialist nurse. Even with the existence of guidelines, the treatment for heart failure in UK continues to be suboptimal, a concern which makes the specialist CHF nurse increasingly valuable (Leslie, 2005). The 80-year-old female client whose care I am monitoring no doubt will find herself increasingly dependent on others, and if she doesn't have proper treatment her quality of life will be greatly diminished. The purpose of this paper is to determine whether this type of care in the community not only will lessen the need for hospital inpatient care but ultimately will create a cost savings as well as a better quality of life for heart failure patients. Need for Further Investigative Studies It must be noted that there appears to be a comparatively high probability of heart failure in certain groups at risk such as those who have had heart attacks or who have hypertension or diabetes, and this may make selective screening in these populations worthy of further study (BMJ, 2000). Since my client has had a heart attack and also has Type 2 diabetes, she could and should be included in such a study. In a situation where cost must be balanced against health outcome, cost estimates for optimum management are necessary in a field of cardiac care that includes several areas of impact on a person diagnosed with heart failure. With the number of medications needed to keep the disease under control, knowledge of contraindications and careful monitoring of medications being prescribed is a priority. My client is a widow, whose husband died about five years ago, and she lives with her son. As long as I am able to monitor her care and continue nurse-led educational intervention (N-LEI), her quality of life should remain on an even keel. Her diabetes is being managed with diet. Cost of Heart Failure in the United Kingdom Cardiac imaging is the best indicator of heart failure in a patient, but in the UK, according to BMJ (2000), only 27% of primary care physicians had direct access to echocardiography at the time of the study, partially due to lack of staff. While the incidence of heart failure continues to rise due to higher survival rates after acute myocardial infarctions and the increasing number of older persons in society, the cost for heart failure patients rises because of inadequate diagnostic follow-up. In a 2003 research article, it was determined that: if, as expected, a home-based programme of specialist nurse management reduced recurrent bed utilization by 50% or more, annual savings equivalent to 169000 per 1000 patients treated would be generated. Our findings suggest that such a service will not only improve quality of life and reduce readmissions in patients with congestive heart failure, but also reduce costs and improve the efficiency of the health care system in doing so (Stewart, MacIntyre, Capewell and McMurray). In 1990 Sanderson recommended the use of angiotensin converting enzyme (ACE) inhibitors as a way to improve both symptoms and survival in all grades of heart failure when given with diuretics. If heart failure is caused by atrial fibrillation, irregular heartbeat, digoxin remains the drug of choice, but diuretics, he says, are the most effective treatment for heart failure symptoms, although they will not cure the disease. A number of randomised trials, including the RALES study, showed that ACE inhibitors had a positive effect (see below). randomised double-blind controlled trial patients involved in the study had severe heart failure (New York Heart Association Class IV) - all patients were being treated with a loop diuretic; most were also being treated with an ACE inhibitor. The ejection fraction of patients was less than 35% patients were randomised to placebo or spironolactone 25-50mg - other treatments were continued. Potassium levels were monitored regularly throughout the study. The dose of spironolactone was increased to 50mg after one month if serum potassium level allowed 1663 patients with severe heart failure were recruited to the study and the mean follow up was 24 months in the spironolactone treatment group there was a 30% reduction in all-cause mortality, lowered hospitalisation rates and improved symptomatic control the incidence of serious hyperkalaemia was uncommon - 1% in the placebo group and 2% in the spironolactone treatment group RALES Study http://www.gpnotebook.co.uk/cache/892665929.htm Although my client had episodes of hyperkalaemia when on spironolactone, it is possible, according to the above study, that there might be a different ACE inhibitor she could take that would not cause this problem. It is certainly worth discussing with her GP. Healthcare and the Ageing Population Life expectancy for older persons has greatly increased, and, because of this the incidence of chronic disease has also increased. People are living longer, but they are also apt to need more medical care the older they get. In the UK this has become a major issue and one that the National Health Service must address. In a country that is based on public health services, the cost of healthcare for older persons is apt to spiral out of control. It must be noted that people entering the workforce at present can expect to live for at least twenty years after retirement, perhaps even more. Chronic health concerns, such as heart failure, become a priority for future study. With advances in scientific study of diseases, there will be a large percentage of older persons who will remain active and healthy, but because longer life does not stop the degeneration of the physical body, eventually these people will be added to the population requiring extended health care. According to the British Heart Foundation, the overall "total direct medical cost of heart failure in the UK each year is currently just over 625 million. Hospital inpatient care is the biggest single health care cost, accounting for approximately 60% of the total cost of heart failure in the UK" (BHF, par. 1). Because of admissions and readmissions related to this illness, community specialist care can do much to improve costs by reducing hospital readmissions. There are contributions and hidden benefits provided by older people within a community, and there is a need to maximize older people's autonomy, dignity and independence, and to minimise the occurrence and impact of disability. In this respect, the heart failure specialist nurse becomes an important part of every community. In a Task Force panel on older people (Healthcare and Ageing Population, 2002) it was noted that the oldest age groups (80+) have the least data collected, simply because people didn't used to live past 80. There is no doubt that a large percentage of the higher costs in health care can be attributed to the ageing population, specifically those with heart failure and diabetes. A great deal depends on the ability of persons suffering from a chronic disease to monitor their own care plans. According to the Task Force, macular degeneration, which leads to blindness and has no cure, is predicted to increase 50% in the next 25 years. Cataract surgery will also continue to be a major expense. Hearing impairment, cognitive decline and weakened muscle strength affect a person's self care. Physical activity programmes have been shown to be a benefit for older persons. With falls an increasing occurrence in the ageing population, it is important to have someone monitor their activities. In 2000 the Government published its NHS plan in regard to residential and nursing care to study long-term care. In the meantime, the plan makes nursing care free in all settings, including nursing homes, rather than making all personal care free to individuals, subject to need. In 1987, Bosson noted that congestive heart failure (CHF) had been the focus of numerous recommendations, since 78% of patients with CHF have at least two admissions per year for CHF exacerbation and 16% have had three admissions per year. It has been speculated that many of the one million CHF hospitalisations that occur each year could be prevented by improved evaluation and care. Quality of Life in Heart Failure Patients In an effort to offer heart failure patients the broadest treatment for their chronic disease, it must be noted that the social aspects of a patient's life, especially in a chronic illness, have been ignored over time and attention needs to be given to various aspects of care in this area. In a society where more and more emphasis is placed on interaction between patients and carers, it is important to respond to the lifestyle of the person under treatment. Quality of life has a great deal to do with health, and a person who is introduced to potential areas of interest such as continuing education or leisure activities that offer physical and mental stimulus have been known to improve physically. The psychological impact of a major life change can be devastating, and for the specialist heart failure nurse, awareness of how a client is dealing with these changes is extremely important. In a case where an older person might be exhibiting signs of dementia such as loss of memory, hostility and anxiety, as well as decreasing ability for self care, it is imperative for the specialist nurse to recognize these symptoms and make every effort to give clients the knowledge that they are not alone. The support of an understanding carer can do much to alleviate the anxiety and fear that dementia can cause. Even without dementia, heart failure is a difficult disease to accept. Patients with heart failure are heavy users of the health care system and therefore require close clinical management and encouragement to manage and identify their symptoms. In the community setting, the specialist nurse is in an ideal position to do this as she has the ability to focus on the both the clinical and social needs of the patient. In order to decrease the frequency and cost of each patient's hospital admission it is essential that inpatient and outpatient care are effectively co-ordinated. The plan of care should include intensive education about heart failure, a detailed drug analysis, early discharge planning and enhanced follow-up through home health care and telephone contact (Bosson, 1997). According to Stewart and Horowitz (2003), based on year 2000 activity levels, it was found that for each specialist heart failure nurse appointed in the UK (with a caseload of 200-250 patients per annum), nominal savings of 49 000 per annum could be generated in order to make the healthcare system more efficient. National Health Service: Heart Failure The Government website for the Department of Health has established the growing need for more studies related to congestive heart failure (DOH: Heart Failure, 2003). Under the National Service Framework (NSF) for Coronary Heart Disease, services for heart failure are a key priority, and a three-year commitment was made to improve heart failure services. The National Institute for Clinical Excellence (NICE) has published guidelines on the management of heart failure, and heart failure projects have been put into place which have led to major benefits for heart failure patients. Reorganisation of the way in which care is delivered was found to be necessary. The NHS Heart Improvement Programme was launched in 2005, and its purpose is to support cardiac network development and introduce recognised clinical innovations. The commission by the HIP of an independent evaluation of how Discovery Interviews can improve care was instituted in May 2005 (NHS: What's New). The use of Internet to disperse information cannot be ignored. The National Health Service has created a programme online called "Rapport" which offers an easily navigated website that covers through patient interviews the various cardiac problems that might arise. Below is the patient journey for heart failure, with a pathway that begins with symptoms and ends with support: Examples of Patient Journeys Select Patient Journey Rapport Online, National Health Service: Examples of Patient Journeys: Heart Failure (2005) Expanding Concerns in Heart Failure Studies A fairly recent survey conducted by researchers behind a nine-country study of heart failure showed that the majority of Europeans surveyed either were not aware or misunderstood the threat of heart failure. Results of the survey were published in the European Heart Journal, the official journal of the European Society of Cardiology, and "although almost 90% of people from the nine surveyed countries - France, Germany, Italy, the Netherlands, Poland, Romania, Spain, Sweden and the UK - said they had heard of heart failure (HF), only 3% could identify the condition from a description of typical symptoms. This was despite 6% saying they had someone in their family with HF" (Europa: Health, Research, par. 3). These disturbing statistics would indicate that even with the efforts being made in the UK to educate the public about heart failure, not nearly enough has been done. Having heart failure specialists in the community would appear to be one of the most beneficial additions to cardiac health care, especially for heart failure patients who require ongoing evaluation and are the most apt to have an exacerbation of their disease and require hospitalisation. Recommendations for Future Care Determining the best method of treatment for my 80-year-old client will be dependent on her continuing daily lifestyle and her ability to understand the seriousness of her illness. In the event that she doesn't fully grasp the need for her to take her prescriptions as directed and to recognize in herself any exacerbating symptoms of heart failure, her chances of readmission to hospital increase greatly. In this respect, my assistance as a heart failure specialist nurse can be considered invaluable, as long as I can continue to gain her trust. Because of the discontinuation of her spironolactone due to increased potassium levels, it might be helpful to check with her doctor to see if there is another ACE inhibitor she could take that might not have that effect. It is also important to educate the client about the signs and symptoms of exacerbation of her heart failure, about setting up a low salt diet, monitoring daily fluid restriction, exercise and the need for a daily weight at the same time each day to make sure she is not retaining fluids. Non-compliance with lifestyle and medicines can rapidly affect her clinical status. Cessation of diuretics therapy, especially in older women, could lead to hospitalization. Because of her NIDDM, close monitoring of renal function with regular assessment is important, especially with the use of beta blockers and ACE inhibitors. In my client's case, serum creatnine and potassium levels were affected by medications, but it is possible that the spironolactone was not the cause. Regular monitoring of her medications and diet, especially if there are changes by her physician, must be managed to make sure she is getting the most benefit from her health care plan. In addition, because she is not taking diabetes medications, her diet must be carefully monitored. In general, the areas of assessment in the care of a patient with heart failure are weight control, use of NSAIDs (low-dose aspirin has been shown to be a risk for renal impairment when used with ACEI and diuretics), smoking cessation if client is a smoker, self-monitoring of blood pressure and heart rate and the importance of follow up. The heart failure specialist nurse has the ability to educate her client and set up a programme that will keep the client stable. Although the nurse is not actually responsible for her client's psychological health, she can be aware of any symptoms of depression, dementia, frustration or feelings of isolation. My client lives with her son and since her husband's death has had to adjust to a different lifestyle. Her illness has added to her need for adjustment, and if I can assist her in dealing with her situation, I feel it is my responsibility to do so. At present, her condition is stable, and her attitude is optimistic. References BMJ (2000). Editorial: Can heart failure be diagnosed in primary care, retrieved 2-22-2006, from http://bmj.bmjjournals.com/cgi/content/full/321/7255/188. Bosson, O., RGN (1997), The role of the heart failure specialist nurse, Priory, retrieved 2-22-2006, from http://www.priory.com/cmol/heartfail.htm British Heart Foundation (2003). Total cost of heart failure to the NHS, par. 1, retrieved 2-23-2006, from http://www.heartstats.org/datapage.aspid=817 Department of Health (2003). Heart Failure, retrieved 2-22-2006, from http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/CoronaryHeartDisease/CoronaryPromotionProject/CoronaryPromotionProjectArticle/fs/enCONTENT_ID=4031386&chk=BUBRm0 Europa (2005). European Research Headlines, par. 3, retrieved 2-24-2006, from http://europa.eu.int/comm/research/headlines/news/article_05_09_15_en.html Healthcare and Ageing Population Panels (2002). Foresight, retrieved 2-21-2006, from http://www.foresight.gov.uk/Previous_Rounds/Foresight_1999__2002/Healthcare/Reports/Older_People/Ageing_Report_6.pdf Leslie, S. J., McKee, S. P., Imray, E. A., and Denvir, M.A. (2005). Management of chronic heart failure: perceived needs of general practitioners in light of the new general medical services contract, Postgraduate Medical Journal 2005; 81:321-326, retrieved 2-22-2006, from http://pmj.bmjjournals.com/cgi/content/abstract/81/955/321 Lyratzopoulos, G., Cook, G. A., McElduff, P., Havely, D., Edwards, R. & Heller, R. F. (2004). Asessing the impact of heart failure specialist services on patient populations, BMC Health Services Research, retrieved 2-21-2006, from http://www.biomedcentral.com/1472-6963/4/10#B5. National Health Service (2005). NHS Heart Improvement Programme: What's New, retrieved 2-24-2006, from http://www.heart.nhs.uk/scripts/default.aspsite_id=23&id=5453 National Prescribing Service Limited (2005). 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PharmacoEconomics, Vol. 21,No. 4, pp. 225-240, retrieved 2-23-2006, from http://www.ingentaconnect.com/content/adis/pec/2003/00000021/00000004/art00001 Stewart, S., MacIntyre, K., Capewell, S., McMurray, J.J. (2003). Heart failure and the ageing population: an increasing burden in the 21st century National Center for Biotechnology Information (NCBI), retrieved 2-22-2006, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgicmd=Retrieve&db=PubMed&list_uids=12482791&dopt=Citation Read More