paradigm shift – inpatient towards outpatient and community oriented care on heart failure...

Paradigm Shift –Paradigm Shift – Inpatient towards Inpatient towards

outpatient and outpatient and community oriented care community oriented care on heart failure patientson heart failure patients

Prepared by Camille K T HOPrepared by Camille K T HO

AcknowledgementAcknowledgement

• Dr. S C LEUNG (HCE)Dr. S C LEUNG (HCE)• Dr. W H CHOW (COS)Dr. W H CHOW (COS)• Dr. E CHAU (SMO)Dr. E CHAU (SMO)• Ms C L LEE (DOM)Ms C L LEE (DOM)• Ms W HUNG (GMN)Ms W HUNG (GMN)• Prof. F WongProf. F Wong• All members of the team (CMU)All members of the team (CMU)

IntroductionIntroduction

• Heart failure is a common and costly Heart failure is a common and costly cause of admissions to hospitals each cause of admissions to hospitals each yearyear

• The cost of heart failure is increasing The cost of heart failure is increasing because the population is living longer because the population is living longer

(Stewart et al 2002) (Stewart et al 2002)

IntroductionIntroduction

Patients with congestive heart failurePatients with congestive heart failure

==

$$$$$$

Unplanned admissionsUnplanned admissions

Unplanned follow upsUnplanned follow ups

Reduce quality of lifeReduce quality of life

Significant morbiditySignificant morbidity

In Hong Kong, the overall incidence was 0.7 In Hong Kong, the overall incidence was 0.7 per 1,000 population admitted to hospitals per 1,000 population admitted to hospitals due to heart failure, with plenty of due to heart failure, with plenty of readmissions and unplanned follow up.readmissions and unplanned follow up.

These preventable negative factors include These preventable negative factors include noncompliance with medications or diet, noncompliance with medications or diet, inadequate discharge planning or follow inadequate discharge planning or follow up, and failure to seek medical attention up, and failure to seek medical attention promptly when symptoms recur.promptly when symptoms recur.

(Leung et al 2004)(Leung et al 2004)

Purposes of the programPurposes of the program

• Empowering the patients in self-management of Empowering the patients in self-management of their heart failure symptomstheir heart failure symptoms

• Improve their quality of lifeImprove their quality of life• Promote their care in the communityPromote their care in the community• Reduce the unplanned readmissions and follow Reduce the unplanned readmissions and follow

upup

Expected ResultsExpected Results

• ↑↑↑↑ Treatment complianceTreatment compliance

• Better symptoms controlBetter symptoms control

• Increase exercise capacityIncrease exercise capacity

• Improve NYHAFC Improve NYHAFC

• ↓↓↓↓ frequency of unplanned follow upfrequency of unplanned follow up

• ↓↓↓↓ unplanned readmissionunplanned readmission

• Transfer back to general cardiac careTransfer back to general cardiac care

MethodsMethods

Participants’ selection criteriaParticipants’ selection criteria

• >18>18

• M/FM/F

• NYHAFC 2-4NYHAFC 2-4

• CAN READ AND WRITE CHINESECAN READ AND WRITE CHINESE

• PRIMARY DIAGNOSIS OF HEART PRIMARY DIAGNOSIS OF HEART FAILUREFAILURE

• REGULAR FU in GH Heart Failure ClinicREGULAR FU in GH Heart Failure Clinic

MethodsMethodsFlow for Heart Failure Clients Home-based Monitoring ProgramFlow for Heart Failure Clients Home-based Monitoring Program

Initial assessment by SMO/Patient Educator (PE)Initial assessment by SMO/Patient Educator (PE)of CMU, GH, in the HFC for suitable participantsof CMU, GH, in the HFC for suitable participants

unsuitable candidatesunsuitable candidates

suitable candidatessuitable candidates

Baseline assessment of patient’s condition obtained Baseline assessment of patient’s condition obtained

PE (Nurse) conduct patient education programPE (Nurse) conduct patient education programfor client enrolled in the home-based monitoring programfor client enrolled in the home-based monitoring program

(Refer to appropriate allied health care professionals prn) (Refer to appropriate allied health care professionals prn)

Patient home–based Monitoring program Patient home–based Monitoring program with Tele-nursing by PEwith Tele-nursing by PE

continue follow up in the HFCcontinue follow up in the HFC

MethodsMethods

1.1. Assessment protocolAssessment protocol• Physical examinationsPhysical examinations• Daily body weightDaily body weight• Daily fluid balanceDaily fluid balance• Drug complianceDrug compliance• Dietary complianceDietary compliance• Exercise toleranceExercise tolerance• Unwanted habitsUnwanted habits• Quality of life Quality of life

assessmentassessment

MethodsMethods

2.2. Apparatus and Measuring InstrumentsApparatus and Measuring Instruments

• Blood pressure monitoring deviceBlood pressure monitoring device

• Logbook with fluid balance chartsLogbook with fluid balance charts

• Quality of life assessment testQuality of life assessment test

• Weight ScalesWeight Scales

• ± Cardiopulmonary exercise test± Cardiopulmonary exercise test

Data analysis of the self-management Data analysis of the self-management programprogram

• Intake and Output balanceIntake and Output balance• Symptoms control Symptoms control • Exercise capacity Exercise capacity • Behavior modificationBehavior modification• Drug complianceDrug compliance• Dietary complianceDietary compliance• NYHAFC statusNYHAFC status• The frequency of unplanned FU / hospitalizationThe frequency of unplanned FU / hospitalization• The length of follow up periodThe length of follow up period

ResultsResults

Patient PopulationPatient Population• From March 2004 to September 2004From March 2004 to September 2004• 31 patients within the selection criteria were 31 patients within the selection criteria were

recruited at convenience samplingrecruited at convenience sampling

• Age Age • 20 – 65 20 – 65 • Mean ageMean age 47.3 ± 10.9 47.3 ± 10.9

• SexSex• Male 26Male 26• Female 5Female 5

ResultsResults

Marital statusMarital status

• Single 7Single 7

• Married 20 Married 20

• Divorce 1Divorce 1

ResultsResults

• Etiology of heart failure were:Etiology of heart failure were:

• Ischaemic cardiomyopathy = 12.9%Ischaemic cardiomyopathy = 12.9%

• Dilated cardiomyopathy = 70.9%Dilated cardiomyopathy = 70.9%

• Acquired valvular disease = 12.9%Acquired valvular disease = 12.9%

• Others = 3.3%Others = 3.3%

ResultsResults

Pre programPre program

Mean ejection fractionMean ejection fraction

= 34.54 ± 10.8%= 34.54 ± 10.8%

NYHAFCNYHAFC• Class I 0%Class I 0%• Class II 16.1%Class II 16.1%• Class III 71%Class III 71%• Class IV 12.9%Class IV 12.9%

Post programPost program

= 42.05 ± 11.8%= 42.05 ± 11.8%

p=0.003p=0.003

6.9%6.9%

79.3%79.3%

13.7%13.7%

0%0%

p<0.001p<0.001

ResultsResults


Body weightBody weight• 70.29 ± 14.2 kg70.29 ± 14.2 kg


• 70.52 ± 13.8 kg70.52 ± 13.8 kg

P=0.281P=0.281

ResultsResults


Average FU durationAverage FU duration• 3 – 15 weeks3 – 15 weeks• 8 ± 3 weeks8 ± 3 weeks


• 5 – 26 weeks5 – 26 weeks• 14 ± 4 weeks14 ± 4 weeks

p<0.001p<0.001

ResultsResults


VO2 maxVO2 max• 17.85 ± 5.04 17.85 ± 5.04

L/kg/minL/kg/min


• 19.91 ± 3.4019.91 ± 3.40

L/kg/minL/kg/min

p=0.093p=0.093

Results Minnesota Living with Results Minnesota Living with HFQHFQ


• 2 - 882 - 88• 33.7 ± 10.3133.7 ± 10.31


• 2 – 592 – 59• 19.4 ± 10.919.4 ± 10.9

p<0.001p<0.001

ResultsResults

ConsequencesConsequences

of the patients of the patients

in their future in their future

carecare

outcome of the patient

outcome of the patient

heart transplant

dead

inactive/long fu

referred back to AC

continue fu

Perce

nt

80

60

40

20

0

DiscussionDiscussion

• As evidenced by this project telephone patients As evidenced by this project telephone patients on a weekly basis to monitor their status, guide on a weekly basis to monitor their status, guide by a standardized protocol and by asking the by a standardized protocol and by asking the same questions with each phone call, Patient same questions with each phone call, Patient educators can quickly detect improvement or educators can quickly detect improvement or deterioration. If the condition is worsening, early deterioration. If the condition is worsening, early intervention can be implemented, often avoiding intervention can be implemented, often avoiding acute exacerbation and hospital admission.acute exacerbation and hospital admission.

Lessons LearnedLessons Learned

• Development of the shifting to Community Development of the shifting to Community Oriented Care HF program was Oriented Care HF program was challenging, challenging,

• Outpatients enrolled in this program Outpatients enrolled in this program greatly benefit from a decrease in greatly benefit from a decrease in recidivism and from improved functional recidivism and from improved functional status, physical endurance, and quality of status, physical endurance, and quality of lifelife

LimitationsLimitations

• This study was a non-randomized trial, the This study was a non-randomized trial, the participants willing to join this program were self participants willing to join this program were self motivated that may overestimate the benefit of motivated that may overestimate the benefit of this programthis program

• It was a relatively small study, larger studies It was a relatively small study, larger studies involving more patients are needed to confirm involving more patients are needed to confirm the efficacy and to identify which patient groups the efficacy and to identify which patient groups will benefit the most from this programwill benefit the most from this program

ConclusionConclusion

• As evidenced by this project, patients coulAs evidenced by this project, patients could be empowered to participate in their own d be empowered to participate in their own care at home and in the community by adecare at home and in the community by adequate education and continuous tele-care quate education and continuous tele-care which could promote healthy behavior as rwhich could promote healthy behavior as reflected by the high adherence to drugs aneflected by the high adherence to drugs and dietary regimen and better symptoms cod dietary regimen and better symptoms control among our clients.ntrol among our clients.

paradigm shift – inpatient towards outpatient and community oriented care on heart failure...

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