Heart Failure Team

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Heart Failure Team by Mind Map: Heart Failure Team

1. Nurse Managers

1.1. W1: Travis Talbot

1.2. W2: Mark S

1.3. W3: Marie Wright

1.4. W4: Emily Snyder

2. Collaborative Teams - What do we want them to know/do?

2.1. Inpatient

2.1.1. Shock Team

2.1.2. Pulmonologist/intensivist

2.1.2.1. Pulmonary Hypertension Clinic

2.1.2.2. Cardiopulmonary Exercise Stress Test CPET CPX

2.1.2.3. Pulmonary Rehab

2.1.3. Hospitalist

2.1.3.1. When to consult HF Team:

2.1.3.1.1. HF with Atrial Fib/Flutter

2.1.3.1.2. HF with CKD/AKI

2.1.3.1.3. HF with Uncontrolled Diabetes

2.1.3.1.4. HF with Anemia

2.1.3.2. When to consult EP

2.1.3.2.1. A-fib/flutter with RVR

2.1.3.2.2. A-fib/flutter with CRT

2.1.4. Cardiothoracic Surgery

2.1.4.1. Cardiac Rehab

2.1.5. Morbidity & Mortality

2.1.5.1. Admit patients for diuresis to reduce mortality

2.1.5.2. Michael Gargano

2.1.5.2.1. MAWDS multidisciplinary patient education

2.1.5.3. Quarterly meetings

2.1.5.3.1. January

2.1.5.3.2. April

2.1.5.3.3. July

2.1.5.3.4. October

2.1.6. Social Work/Case Management

2.1.6.1. BOOST Risk Stratification Tool

2.1.6.2. Psychosocial issues associated with HF contributing to readmission

2.1.6.3. Invite to morbidity and mortalitymeetings

2.1.7. MAWDS Multidisciplinary Patient Education Clinical Pathway

2.1.7.1. Partners in healing

2.1.7.2. Medications

2.1.7.2.1. Pharmacist champion?

2.1.7.3. Activity

2.1.7.3.1. Cardiac Rehab champion: TJ

2.1.7.4. Weight

2.1.7.4.1. 1 Nurse & 1CNA champion per floor

2.1.7.5. Diet

2.1.7.5.1. Dietitian champion

2.1.7.6. Symptoms

2.1.7.6.1. 1 Nurse & 1CNA champion per floor

2.1.8. -

2.2. Outpatient

2.2.1. Primary Care Providers

2.2.1.1. SGLT2 inhibitors

2.2.1.2. Medication reconciliation

2.2.2. Nephrologist

2.2.2.1. Cardiorenal Clinic

2.2.2.1.1. Use of Cystatin C to evaluate for AKI

2.2.2.1.2. Coordinate with nephrologists - Dr. Mercado, Dr. Boateng 1 - 2 days per month each.

2.2.3. Oncologist

2.2.3.1. Prescreen all patients with echocardiogram when initiating anthracycline

2.2.3.1.1. Risk factors for chemo induced cardiomyopathy: HTN, DM, CAD, Valvular Heart Disease, Preexisting Cardiomyopathy

2.2.3.2. Genomics

2.2.3.2.1. RXMatch use in clinic, send to PCP’s

2.2.4. Rheumatologist

2.2.5. Endocrinologist

2.2.6. Sleep Clinic

2.2.6.1. Increase initiation of inpatient CPAP

2.2.7. SNF’s/Rehabs

2.2.7.1. See patients from SNF/Rehab within 1 week after discharge home: NP?

2.2.7.2. Outreach for education at staff meetings

2.2.7.2.1. Bella Terra - done

2.2.7.2.2. Coral Desert - Oct 10, 2018 @ 3pm

2.2.8. Home Health

2.2.9. Electrophysiology

2.2.10. TAVR/Valve Clinic

2.2.11. Dietitian

2.2.12. Pharmacist

2.2.12.1. Outpatient pharmacy outreach

2.2.12.2. Medication advocacy for Jardiance, Entresto, Veltassa,

2.2.12.3. Red and Green bag use in clinic

2.2.13. Dr Melonie Atwood, and Tom Denhalter NP

2.2.13.1. Invite to HF committee meetings

2.2.14. Dr. Ashanaki

2.2.14.1. Invite to HF committee meetings

2.2.15. Palliative Care

2.2.15.1. Revive palliative care team

2.2.15.1.1. Dr. Willis, Dr.Haslem, Dr. Moon (switch to Ferguson?), Dr. Parkinson (switch to someone else)

3. Multidisciplinary Heart Failure Team Members & Roles

4. HF Team Quality Improvement Goals

4.1. Outpatient

4.1.1. Intake questionnaire

4.1.1.1. Decrease clinic visit time

4.1.1.2. Increase resource utilization

4.1.1.3. Focus clinic visit topics

4.1.1.4. What to include

4.1.1.4.1. GAD7

4.1.1.4.2. PHQ9

4.1.1.4.3. QOL

4.1.1.5. What is the questionnaire assessing?

4.1.1.5.1. Before HF team well being score

4.1.1.5.2. After HF team well being score at 3 months, at 6 months, at 9 months, at 1 year

4.1.2. Seattle HF model - Predictive Survival

4.1.2.1. 3 years 2015-2017 in iCentra

4.1.2.2. 2014-2016 in Help 2

4.1.3. Medication reconciliation

4.1.4. Improve use of imaging

4.1.4.1. Accreditation of echocardiogram team

4.1.4.1.1. Adoption of strain imaging

4.1.4.2. MRI, PET

4.1.4.2.1. MRI: equipment, proctor & imager

4.1.4.3. DRMC as a HUB of care not a spoke- need resources and equipment to do so

4.1.4.3.1. Patient access to care

4.1.4.3.2. Stop sending business and revenue to SLC

4.1.4.4. Decrease threshold for treadmill NM studies

4.1.5. Rural outreach

4.1.5.1. Telemedicine

4.1.5.1.1. Evidence based HF medicine taken to the rural patient

4.1.5.2. Echo van outreach

4.1.5.3. Cardiomems

4.1.6. -

4.1.7. Patient interactive HF app & Facebook page

4.1.7.1. MAWDS

4.1.7.2. App

4.1.7.2.1. Wellbeing questionairres

4.1.7.2.2. Medications: med list, med alarm, medication checklist of pills taken- by picture and name, medication photos, pill identification

4.1.7.2.3. Activity: pedometer, activity tracker

4.1.7.2.4. Weight: goal dry weight, enter daily weight, weight graph

4.1.7.2.5. Diet: daily food entry, track Na+ intake, track fluid intake, recipes- low sodium

4.1.7.2.6. Symptoms: urine output, weight trend, symptom checklist- instructions based on score, Red/Yellow/Green

4.1.8. Medication titration clinic

4.1.8.1. Protocols

4.1.9. Diuretic/potassium clinic

4.1.9.1. Protocols

4.1.9.2. SR/Obs for urgent diuretic infusion clinic

4.1.9.2.1. Call CN for approval- if there is staff and a room available, then: give orders, discharge instructions, and if/then orders

4.1.9.2.2. Already using for albumin infusions for paracentesis, CT hydration

4.1.10. Cardiac/HF medication education campaign

4.1.10.1. Aldosterone blockers

4.1.11. Optimize clinical collaboration with SNF’s

4.1.12. Cardiomems

4.1.12.1. Pays for itself in 1.5 years

4.1.12.2. Rural health

4.1.13. Amyloid

4.1.14. Notebook

4.1.15. Urinals/Hats in clinic

4.1.16. Palliative care

4.1.16.1. Plan for events when patient does not want hospital admit- or to come to the ER

4.1.17. Transplant patients in St. George

4.1.17.1. Collaborate with IMC

4.1.17.1.1. Laboratory testing

4.1.17.1.2. Notebook copies - electronic version?

4.1.17.1.3. Transplant coordinator- 10-12 patients per coordinator. Social worker. Financial liaison. RN care manager - inpatient x2, outpatient x1. Pharmacist outpatient x1, inpatient x1. Research coordinator.

4.1.17.2. Collaborate with other facilities

4.1.18. HF clinic services provided?

4.1.18.1. EMR?

4.1.18.2. Home based weight monitoring?

4.1.18.3. Electronic pill box?

4.1.18.4. Hospital discharge transition clinic?

4.2. Inpatient

4.2.1. Increase initiation of inpatient CPAP

4.2.1.1. -

4.2.2. Medication reconciliation

4.2.2.1. Transitions from hospital to SNF

4.2.2.2. Transitions from SNF to home

4.2.2.3. Red / Green bag - all home meds

4.2.2.4. Medication organizer filled for 1 week

4.2.3. Tactical discharge

4.2.3.1. Decrease readmission related to medication reconciliation issues

4.2.3.2. Decrease readmissions related to psychosocial issues associated with HF

4.2.3.3. Decrease readmissions related to fluid volume overload issues associated with HF

4.2.3.4. Hard stop discharge checklist

4.2.3.4.1. Off IV diuretics for at least 24 hours

4.2.3.4.2. Pharmacist education

4.2.3.4.3. No changes to medications in 24 hours

4.2.3.4.4. Dietitian education

4.2.4. Labs

4.2.4.1. Cystatin C

4.2.4.2. Urine sodium spot check 2 hrs after diuretic dosing

4.2.4.3. Amyloid screening

4.2.5. Fluid volume assessment

4.2.5.1. Fluid Volume Congestion

4.2.5.1.1. BUN, Creatinine elevated, Cystatin C, Urine sodium, LFT’s elevated

4.2.5.1.2. Symptoms: Abdomen: distention, bloating, early satiety. Headache: fullness, throbbing like heartbeat in ears, congestion. Respiratory: dyspnea on exertion, orthopnea, dyspnea at rest when sitting with abdominal distention.

4.2.5.1.3. Physical Exam: assess JVP by changing bed position. JVP elevated-(pulsation, not necessarily distention) Respiratory: Labored, rales in bases, tachypnea. Abdomen: distended, tight, liver congestion/pulsatile. Extremities: pitting edema- press on shin bone, sacral, scrotal, abdominal,wall edema.

4.2.5.2. Fluid Volume Depletion

4.2.5.2.1. Labs: BUN, Creatinine elevated, Cystatin C, Urine sodium, LFT’s not elevated-(unless other underlying process)

4.2.5.2.2. Physical Exam: assess JVP by changing bed position. JVP Below clavicle until laid flat-Respiratory: unlabored, even respirations, no rales. Abdomen: soft, non-distended. Extremities: No generalized edema- or possibly lymphedema -press on shin bone.

4.2.5.2.3. Symptoms: Severely fatigued. Abdomen: nauseous. Headache: lightheadedness, orthostatic, seeing stars/tunnel/black when first standing. Respiratory: no dyspnea, no orthopnea.

5. Patient Lists

5.1. End Stage Heart Failure - Stage D

5.1.1. Multiple Readmissions

5.1.2. Escalating diuretics

5.1.3. Frequent episodes of VT

5.1.4. No longer tolerating medications - de-escalating

5.1.5. Nutritional decline, cachexia

5.1.6. Falls

5.1.7. Symptomatic despite euvolemia

5.2. Multiple Readmissions

5.2.1. MIH

5.2.2. Cardiomems

5.2.3. Beat HF

5.2.4. Home Health

5.2.5. Community Health

5.3. Transplant

5.4. LVAD

5.5. Cardiomems

5.5.1. Business plan

5.5.2. Rural health- lack of access to frequent HF specialist visits for volume assessment

5.5.3. Any admission for fluid overload within the last year

5.6. Beat HF

5.7. MIH

5.8. SNF/Rehab

5.9. Home Health

5.10. Palliative Care

5.10.1. Patients currently on Palliative Care

5.10.2. Patients to consider for Palliative Care

5.11. Rheumatology

5.11.1. With rheumatology consults

5.11.2. To refer

5.12. Entresto

5.13. SGLT2 inhibitors

5.14. A-Fib/Flutter

5.15. CRT-d/CRT-p

5.16. LVEF <35%

5.17. -

5.18. Rural Areas

5.18.1. Caliente

5.18.2. Richfield

5.18.3. Page

5.18.4. Kanab

5.18.5. Panguitch

5.18.6. Beaver