4/14/201 3

Welcome Before viewing the recorded session, please access the files below and print the documents to use as a reference during the presentation.

Because this is a recorded session, you will not be able to click directly on the links. You will need to copy each address and enter it into your browser in order to open each document. You should print all three documents.

• http://tinyurl.com/d32aw6t (Slide Presentation Handout)

• http://tinvurl.comiczyfIg4 (4-Day Process Flow)

• http://tinvurl.com/d9dvbnb (Patient Assessment Guide)

Home Health Agency (HHA) Heart Failure & Inotrope Therapy

Education Module

Jodie Lockman-Samkowiak, MSN RN CRNI Doctor of Nursing Practice Student Madonna University

• The planners and faculty have declared no conflict of interest.

• Completion of the entire webinar and the

evaluation is required to obtain contact hours for this event.

Heart Failure Background

Heart Failure The Problem

• The American Heart Association estimates:

• 5.8 million Americans have HF with 670,000 new HF cases diagnosed annually

• $34.4 billion in healthcare services, medications, and lost productivity

• The majority of this cost is in the late stages of heart failure

• Over 20% of discharged patients are readmitted within 30 days

Objectives The participant will be able to :

• Describe the clinical presentation of advanced left ventricular systolic (LVS) heart failure (HF) in adults.

• Describe the comprehensive management plan for the patient with advanced LVS HF.

• Provide patient and caregiver education for home inotrope therapy

• Demonstrate infusion-related care and safety of the patient receiving inotrope therapy in the home setting.

• Identify pharmacy, home health care nurse, patient and caregiver responsibilities and roles.

• Describe the goals of home inotrope therapy. o improve overall blood flow

o Increase organ perfusion o Reduce symptoms

• Describe the infusion-related care and safety of the patient receiving inotrope therapy in the home setting.

1

The Remodeled Heart

Healthy Heart Remodeled Heart

National Heart, Lung & Blood Institute, US Dept. Health & Human Services, National Institutes of Health

Heart Failure Types

Systolic heart failure

Diastolic heart failure Depressed ejection fraction

Preserved ejection fraction

Ejection fraction(En

A measurement of the amount of blood pumped out of the left ventricle with each heartbeat.

4/14/2013

Transitional Care

• 19.6 % of Medicare patients are readmitted within 30 days of original discharge

• A large number of re-admissions are avoidable • High readmissions = financial penalties for hospitals

Heart Failure Defined

Heart failure (HF) is generally defined as a chronic disease characterized by the inability of the heart to pump an adequate amount of blood, to achieve the demand of the different organ systems, and/or doing so at increased filling pressures.

Nasd m, Ala.. A CcogeseveHeart Failure a. Public Health www kw, ecisiftne0/epidtsioimpl.639/ConglleartFail.or

Heart Failure Clinical Presentation

• Decreased exercise tolerance

• Fluid retention

• Need to sleep with more pillows or in recliner

• Arrhythmias

• No symptoms of HF, but are found to have evidence

of cardiac enlargement or dysfunction during

evaluation

Jessup M, Alsra.ns MT, Casey Of , Feldman AM, Francis GS, Genies Te, itonstarn MA, Mancini DM, Ratko PS, Silver MA, Stevenson

LW, Tancy CW, 2[103 focused update: ACCF/ AMA Guidelines for the Diagnosis and Management of .art Failure in Multi:a report or the Arnerican College of Cardiology Foundation/American klean Association Task Force on Practice Guidelines:developed in collaboration with the InMmational Society for Haan and Lung Transplantation,Circulation 200.3,119(14),1977.2016.

Classifications/Stages

New York Heart Association (NYHA) Functional Classification

American College of Cardiology/American Heart

Association (ACC/AHA) stages

• Class I: no limitation of activities; no symptoms from ordinary activities

• Class II: slight, mild limitation of activity; comfortable with rest or with mild exertion.

Class III: marked limitation of activity; comfortable only at rest.

Class IV: should be at complete rest, confined to bed or chair; any physical activity brings discomfort, symptoms Occur at rest.

• Stage A: High risk for HF, no structural heart disease or symptoms

• Stage & Heart disease with asymptomatic left ventricular dysfunction

• Stage Prior or current symptoms of HF, known structural heart disease, shortness of breath, fatigue, & reduced exercise tolerance

• Stage!): Refractory end stage HF, marked symptoms of HF at rest despite maximal medical therapy, e.g. those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions

2

4/14/2013

Treatment of Heart Failure

AHA Get with The Guidelines International Guidelines are similar

o Remove precipitating or exacerbating factors

o Lifestyle modifications

o First line drug therapy:

• Angiotensin Converting Enzyme (ACE) inhibitors + Angiotensin II Receptor Blockers (ARBs) decrease blood pressure and improve blood flow from the heart to the vessels

• Beta blockers

• Spironolactone and eplerenone

• Loop diuretics

— Treatment of sleep apnea

— Treat atrial fibrillation

— Anticoagulation

— Exercise Training

httro//www..artorg/HFARTORG/Healthcarenesearch/rtert,thahertuidelinesHaStrokeirtetWitrtrheenidelinesHeartealloreHornenage irereet-Fir_OCNI307433_SubHomenane,ian

=man, Ober Mehra, 2010. Chronic Heart Hinge: contemporary diagnosis and management Moyo <folk Ploceedings.85121, 180-

Advanced Heart Failure

Treatment of Advanced HF

Device Therapy

• Cardiac resynchronization therapy (CRT)

• Implantable cardioverter-defibrillator (ICD) • Treat mitral valve regurgitation

• Ventricular assist devices (VADs) — Bridge to transplant — Destination therapy

• Continuous inotrope therapy — Bridge to transplant — Destination therapy

• Cardiac transplantation

Gram libX. HORS, MA O= Newt Wore mirmocory damn end Rummel. 145,0 WIC Proceed res02).181).195

MOW

A Word About VADs An internal heart pump placed to help Opportunities with VADs

blood pump through the lungs and back • Inotrope bridge

out to the body. A cardiologist may use • Anti-infectives

inotropes, VADs or both • IVIG (transplant)

0

• ssast *nee (WIWI conmetee to howl - Bett•ry

A cable coon•als Ow edee1101011■••• LAU sad tame 1...0 Mom. • sotall norm the atclome• - - Co.°, u., _A

..,^,e0q.a,t10ealtn.topics/topics/.0

"

MAW hi

- Lared) putrges Mood van wen atula 110 the max, 1.

-----

Mo. Nom the toft wow,. eotees the

\ tA0.17 \

4.)....: .X.

.........„

WAD Cab. 0..0.9 to owe. unil

on or••••••alton

Inotrope Therapy

Infusion Nurses Society(INS) Standards of Practice

• INS is the global authority on infusion nursing

• Foundation in evidence-based research

• Should be the basis of all agency infusion related policies and procedures.

• INS web site has a multitude of publications

www.insl.org

3

• Increase dysrhythmias

• Drug tolerance/decreased

effectiveness

• increase mortality

Inotrope Drugs

• Dopamine is rarely used in home infusion

• Dobutamine and milrinone are common

— Milrinone preferred with beta-blockers

• D5W is typical diluent due to sodium restrictions

• increase contractility

• improved ventricular relaxation

• increases vasodilation

Gonseesti EZ,Chu EC, Reese 15 Shishehbor PAH, Hsieh E, Sterling RC. Prognosison chronic. Polautamine or ,,'snore infusions . stage Cr

heart Whim. Um Heart Fail. 2109; 2:3206. there sere no mortality differences between chronic intravenous dobutarnine or milrinone in

W iens with stage 0 heart railure being discharged from the hospital. The high mortality in this group seetted M inorroPeclePentence

warrants careful consideration of all options and priorities for further care.

Risk/Benefit of Inotropic Infusion

Positives

• Enables discharge from hospital

• Improves quality of life

• Fewer rehospitalizations

N egatives

• Catheter related bloodstream infections

• Increase in mortality

• Burden on family

4/14/2013

Inotropes are indicated for the Treatment of Refractory Heart Failure (Stage D)

"These individuals represent the most advanced stage of heart

failure and should be considered for specialized treatment

strategies, such as mechanical circulatory support,

continuous intravenous positive inotropic therapy, referral for

cardiac transplantation, or hospice care."

Source: Mesas le, Abraham WT,Cesey DC Feldman MA, Panes GS, Ganiats TG, esestarn Men Mancini DM, SM. PS, Silver Me, Stevenson

LW, tansy CPC POPP focused update. ACCFP1He Guidelines for the Diagnosis and Management of Heart Failure in Mulls: a report of

Me American Cole', of Cangiology ForindMn/American Heart Association Task Some on Practice Guidelines. developed in LOR.O.01,111ith the International Society foe Heart and Lung Trermiranorion. Circulation 2009.119114):1977.2016.

Indications for Inotrope Therapy

• Short-term therapy for acute management of decompensation

• Bridge to transplantation

• Palliative end of life care

• Inotrope therapy purpose is to:

c improve overall blood flow

c. Increase organ perfusion

o Reduce symptoms and improve the patient's quality of life

• The goals of a home inotrope program are to:

o Decrease HE exacerbations

• Decrease ER visits

o Decrease hospitalizations

Stevenson 50 Clinical use of mourner therapy . heart failure. ng rd 2 Pan II:Chronic inotrepic Merest.

Circulation 2003; 108. 092-497

✓ Initiating, ✓ Maintaining

✓ Troubleshooting Home inotrope Therapy

Phermaty HOMe Health Agency Inotrope Patient Diuharge Planning: Day 1

Responsibilities Responsibilities

Swerve refer.. mewl collaborative i mew Peete epics ISISPIrewhes newel

hop Ssutem ReSpOnsibliities L.—oieurvivasiimituvroe---1

Nowt mires reneurieruent am..a Mee 1.ii Nem mews*

releiblitai !met.... mewed smerwersoi wee

cc.

• ,,

v beam er 0 ll M P.M • Verieseirde sec...delivery ...saw aii

Sernspavnicinfiremarion • PearnmevesPromIlteluerg.eureng

prow,. asomecemewiwywact

i) com.aonri..P/C Comm miae,

. emcee mparecess.*•perie

marwestemeceeel. Devrium Sconlinnwhe a babas means

canon CSC ciemer

Woe game *Won purse freartel05 • Demelm•senfirrneamee clet•Mr• el CdC

froammusel

Calbearale with *mow

co -

PO

4

Pharmacy

Home Health Agency

Responsibilities Inotrope Patient Discharge Planning : Day 3

Responsibilities

Early AM Collaborative riy AM

• l'atlent n stable.. dam of motropes panwrmnmuml Itasooroilabities comm.:awe we....

• Wegner WHIN evalla.for tnmaltaach at has... • CommulkstetoW.SA

pplvt hook,.

Upon Discharge

Patrenntamesi.

• mesh...mem. nem eme wed Minim • Ve.e.elerstancln.of nen scheduled

one.hage

upGH OisCildirge

mat determiners

• Menem memrtarem

mer miming &name

mrcom , • veris seem emne me mime mem. eat

merde - • verryneardamonmenismnsa

Late an Uay of Discharge

tate Oily of Uisdiarge

• Verlrythat remainder of shipment arrived at home and

• VeZVole7ea7th agency number and plam • V se's name & planned rt. [In.

• Call patient and chef, on status once home

Pharmacy

Responsibilities Inotrope Patient Ongoing Care and Collaboration

Home Health Agency

Responsibilities

patient refillassessTm

• =arre naOttrnr!:;la:resuits memento emdian

Pm" -tt

temenearetiver Mewled. or credal mranmess

4/14/2013

Pharmacy

Responsibilities Inotrope Patient Discharge Planning : Day 2 Home Health Agency

Responsibilities

''' "'""'"'""'

Collaborative Responsibilities rt" ---.

ineren•nmemen )

i odenen amnions rename min...ram

•

.. =Teem. tar awns

health care plan an0 expectations

• verify...1.e and answer env [mast...,

="r====r electncit,911sern.0

• Call local FASto inform them of ...rope patient in their areal

tn.,. • Verity ureg.ver will be arailalaktormtlal teach /hookup

......"'.'".'''''''''''` • tn=t texhIng will be ebile initlal

• ....V* c chititlfaffailiM Caine

fa w;,rmawam xxA was

expected Interventions

. n ion vdtil physician.. ossues re corn

• sou c.peclaticcs of pha , nlacvan01.11.

Home Inotrope Infusion Program

• Why Home?

o Decreased infection

o Decreased costs

o Improved quality of life

Marne, , Rao V-, Ong., RH. et al. (HOER Chores: a study of preferences for end of liferof life treatment$ in oedema with advanced

Mart Wine. roomer of Heart and Lung TranSPlar , , nisi, topzaapT.

Fried, T 0014 Redefining the 'Omni," in advance <are planning: oreoadrte for enrol life decision making. Annals of

Internal Medicine,153(6), 256-261.

Patient Selection and Qualification

Appropriate Patient Selection Medicare Part B Qualification

• Patient is clinically stable on current dose of isotropic therapy

• Central venous access established

• Stable fluid and electrolyte balance

• Home environment (phone, environment safe, water, emergency services available)

• Patient/care partner willing to learn

• Compliance

• Reimbursement criteria met

• Dyspnea at rest or mild exertion prior to inotropes with improvement following initiation of therapy

• Hemodynamic monitoring to show improvement of 20% in cardiac index and reduced left

. ventricular and diastolic pressure

• Able to be monitored regularly by MD

• On digoxin, diuretics, vasodilators without response (can do letter of medical necessity)

• Specific dosage ranges

Home Inotrope Therapy Program

• Drug Therapy - Milrinone - most common inotrope therapy

• Loading dose: 50mcg/kg

• Adult dose

Infusion rate Total daily dose (24 hr)

Minimum 0.375 mcg/kg/min 0.54 mg/kg

Standard 0.50 mc / :/min 0.72 m• /k

Maximum 0.75 mcg/kg/min 1.08 mg/kg

• Continuous infusion via pump at a prescribed rate

5

Home Inotrope Infusion Program

• Drug Therapy — Dopamine

• Loading Dose: ?

• Adult and Pediatric Dose

Fpocranes com

4/14/2013

Home Inotrope Infusion Program

• Drug Therapy - Dobutamine • Loading dose: none

• Adult dose

Infusion rate Total daily dose (24 hr)

Minimum 1 mc• /k•/min 1.44 m /k

Standard 2-20 me: /k: /min 2.88 — 28.8 m:/

Maximum 40 mc /k /min 57.6 m:/

• Continuous infusion via pump at the prescribed rate

Home Safety Considerations • Two pumps always available in the home

• Regular change of batteries

o Do not allow batteries to be completely drained

• Refill of drugs delivered prior to last bag being used

• Use of thrombolytic drugs to dissolve clots within the venous access device

• Peripheral IV order available

• Phone availability

• 911 emergency availability

(Gautman, Uber, Mehra, (2010). Chronic Heart Failure: Contemporary diagnosis and management. Mayo Clinic Proceedings,85(2), 180-1951

Special Concerns:

• Do not flush the continuous inotrope IV line without a physician's order

• If intermittent: flush line slowly to avoid bolus of inotrope

• Instruct to place back up pump on patient first; then reset other pump.

• Instruct to rotate bags of medication to prevent expiration.

• Always have an extra bag in the home

• Assess need for IV diuretic (notify MD of continuous weight gain not responding to oral diuretics). >2 pounds/wk

• Notify MD/pharmacy of 5 lb weight gain in 24-48 hours • Notify MD/pharmacy of increase in resting pulse of 30 or

more

Typical Inotrope Therapy Supplies Provided by Home Infusion Pharmacy

Educational materials

Extra medication bags in the refrigerator (with tubing connected)

Extra programmed pump

Pump batteries

Extra pump tubing

Sterile alcohol pads

Extension sets

Needleless caps

Sterile central line dressing kits

Non-coring needles (if patient has a port)

Saline flushes

Heparin flushes

Tape

Home Health Care Visit Frequency "Front-Load" visits to concentrate on teaching and verification of understanding. Example:

• Week 1— Daily Visits

• Week 2— Every Other Day Visits

• Week 3 — 2 times per week

• Week 4— Weekly and as needed

• Do not decrease visit frequency if patient/caregiver understanding and compliance is questionable.

• Increase visit frequency if changes in dose/regimen changes

• Increase visit frequency if changes in critical parameters occur

• 1 X per week visit frequency is minimum when stable on home inotrope therapy

6

This document is to be used in the home care nurse as an assessment guide to assure all aspects of

pollen therapy and tare one addressed during a home health visit or telephone aSSeSSIMMI. The nurse

should document against all of the following each home care visit and each telephcae assessment with

the patient caregiver Phrsieiam must be notified when assemsment mulls are diatilie Ar101.11491IPS,

Tke failowim, art ahe pardon...vs sedan

Patient •ame DOB;

Acceptable Par=mrs per Dr.

(Report variances ia parameters to bath pharmacy and physician)

Weight Gal of: pounds in hours

B/P Outside a( Rasp: Sastolic: Diastolic

Poise: < or >

Tampers...re: Report temperature > f

taide.M.Yynniakaowdn non...Lean!.

Critical Parameters/Assessment

4/14/2013

Typical Lab Tests

• Creatinine

• Compete Blood Count (CBC)

• Urinalysis

• Electrolytes

• Liver Function

Ongoing Monitoring Requirements

Assess With Each Visit and Report Changes in:

• Vital signs

• Central Line Complications

• Heart rhythm

• Pain assessment (including chest pain)

• Weight

• Dyspnea, orthopnea, paroxysmal nocturnal dyspnea

• Edema

• Lung sounds (rates)

• Ascites

• Hepatomegaly

• Dizziness

• Confusion

• Depression

What if the inotropic drug dose has

been changed?

It is important that the home care nurse increase visit frequency when there is a dose change if seeing the patient infrequently such as weekly. An example:

• Increase visits to every other day X 1 week then resume previous schedule once stable on new dose.

Assess for changes in:

• Blood pressure

• Pulse pressure (narrower)

• Changes in circulation:

• Pallor

• Dizziness

• Mental status changes

• Pulmonary changes

Home Visit • Use the Home Motrope Therapy Patient Assessment Guide!

• Verify accuracy and appropriateness of inotrope therapy following the "5 Rights":

• Right Patient

• Right Drug

• Right Dose

• Right Route

• Right Time

• With inotrope therapy it is important to verify the drug

• Concentration

• solution (diluent)

• Volume

• Verify pump settings/rate of administration

• CVAD assessment/care

• Draw lab specimens peripherally if possible • Reinforce essential patient teaching

Patient/Caregiver Education: • Infection control

• Intended therapeutic effects

• Appropriate storage and handling of medication

• Inotropic therapy administration

• Pump operation, alarms and troubleshooting

• Emergency plan for interruption in therapy

Paeo e•we

Edolc•..dceic,fri

7

Patient/Caregiver Education (cont.)

• Signs and symptoms of worsening heart failure

• Care, maintenance, and safety of central line

• Signs and symptoms of CVAD complications

• Signs and symptoms of severe side effects/adverse drug

reaction

• Adverse effects of inotrope therapy

• Diet (low sodium / low fat) and fluid restrictions

• Monitor and record daily:

— Vital signs (BP, Pulse, Temp)

— Weight

Central Line Assessment & Teaching

Central line infection is common reason for rehospitalization especially after decrease in home health visit frequency

Sterile technique must be maintained by patient/caregiver for all central line accessing and

bag changes.

Ongoing verification of compliance with sterile

technique is necessary even after patient/caregiver has

demonstrated independence

Additional Patient Assessment (cont.):

• Assess diet compliance (low salt/low fat)

• Changes in health status that suggest worsening heart failure

• Changes in health status that suggest decline in renal function

• Drug interactions:

— Inotropes require a dedicated line and no other IV drugs should be given through that line.

— Imipenem (primaxin)

— Antihypertensives (potentiated by milrinone)

— Diuretics (may necessitate a reduction in dose)

4/14/2013

Home Patient Education

• Adherence to medical regimen

• Medication side effects

• Signs and symptoms of infections

• Signs and symptoms of worsening heart failure

• Self-monitoring (e.g. daily weights. temperature)

• Low sodium diet

• Fluid restrictions

• IV site care, infection control

• Make healthcare team aware of changes in insurance

• Ongoing confirmation of compliance is critical

Additional Patient Assessment:

• Activity level and ability to perform ADLs

• Loss of energy

• Is the patient/caregiver self-monitoring and implementing:

— Behavior changes

— Daily weight monitoring

— Adherence to diet

— Symptom management methods

— Smoking cessation

— Avoiding unsupervised use of NSAIDS

Medication compliance

Continuous Inotrope Infusion: • Remove medication bag with connected tubing from refrigerator

• Gather supplies (extra pump with new batteries)

• Turn pump on and verify settings

• Connect to pump

• Prime tubing per manufacturer's manual

• Stop the pump that is on the patient

• Disconnect old tubing and pump from patient

• Cleanse needleless connector vigorously with sterile alcohol pad

• Connect new tubing and pump to patient

• Press START button on new pump and verify infusion

• Disconnect tubing from old pump

• Reset "old" pump so that it is ready to use if needed

• Turn off "old" pump

• Change batteries in old pump

8

Documentation • Standing orders for anaphylaxis treatment

• Medication:

— Name

— Dose

— Diluent & volume

— Concentration

— Rate of infusion

• Pump settings:

— ml/hr — Before and after container/bag change if applicable

• Procedures and medication administration performed

• Patient teaching done

• Observation of return demonstration

• Response/understanding of information taught (teach-back)

• If you have further questions related to patient-related care, contact

designated infusion pharmacy providing services for your particular patient.

• For questions related to this presentation, I can be reached at jlockmansamkowiak@my.madonna.edu

4/14/2013

Intermittent Inotrope Therapy

• Obtain baseline vital signs prior to infusion

• Remove medication bag with connected tubing from refrigerator

• Gather supplies (extra pump with new batteries)

• Turn pump on and verify settings

• Connect to pump

• Prime tubing per manufacturers manual

• Cleanse needleless connector vigorously with new sterile alcohol pad each time before connecting syringe or tubing.

• Flush CVAD with 10m1 saline

• Connect tubing

• Press START

• Repeat vital signs every 10-15 minutes % 1 hour after infusion begins

• At end of infusion, disconnect tubing and flush CVAD SLOWLY with 10m1 of saline followed by ordered heparin flush.

• Turn off pump and reset (change batteries as directed).

Ongoing Assessment

• Ability of caregiver to follow technique and instructions ongoing for inotrope bag changes, oral medication therapy and CVAD management.

• Assess need for increase in home health care visits

• Recommend telephoning patients between visits when initial decrease in visit frequency occurs.

Remember...

• Communication is key to the success of inotropic therapy

• Pharmacy is on call 24/7

• Pharmacy number is on all medication labels and on folder that arrives with the initial supply delivery

• Assure that patient has pharmacy phone number at fingertips

• Collaborate with physician AND pharmacy, patient/caregiver.

Survey Link

• This is a recorded session. You will not be able to click this link directly.

• Please copy or write down this URL and type it in your internet browser to access the survey.

• Completion of the survey is necessary in order to receive your continuing education credits.

http://tinyurl.com/cat3bdy

1