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 Pulmonary Hypertension Clinic Cardiopulmonary Exercise Stress Test CPET CPX Pulmonary Rehab

2.1.3. Hospitalist When to consult HF Team: HF with Atrial Fib/Flutter HF with CKD/AKI HF with Uncontrolled Diabetes HF with Anemia When to consult EP A-fib/flutter with RVR A-fib/flutter with CRT

2.1.4. Cardiothoracic Surgery Cardiac Rehab

2.1.5. Morbidity & Mortality Admit patients for diuresis to reduce mortality Michael Gargano MAWDS multidisciplinary patient education Quarterly meetings January April July October

2.1.6. Social Work/Case Management BOOST Risk Stratification Tool Psychosocial issues associated with HF contributing to readmission Invite to morbidity and mortalitymeetings

2.1.7. MAWDS Multidisciplinary Patient Education Clinical Pathway Partners in healing Medications Pharmacist champion? Activity Cardiac Rehab champion: TJ Weight 1 Nurse & 1CNA champion per floor Diet Dietitian champion Symptoms 1 Nurse & 1CNA champion per floor

2.1.8. -

2.2. Outpatient

2.2.1. Primary Care Providers SGLT2 inhibitors Medication reconciliation

2.2.2. Nephrologist Cardiorenal Clinic Use of Cystatin C to evaluate for AKI Coordinate with nephrologists - Dr. Mercado, Dr. Boateng 1 - 2 days per month each.

2.2.3. Oncologist Prescreen all patients with echocardiogram when initiating anthracycline Risk factors for chemo induced cardiomyopathy: HTN, DM, CAD, Valvular Heart Disease, Preexisting Cardiomyopathy Genomics RXMatch use in clinic, send to PCP’s

2.2.4. Rheumatologist

2.2.5. Endocrinologist

2.2.6. Sleep Clinic Increase initiation of inpatient CPAP

2.2.7. SNF’s/Rehabs See patients from SNF/Rehab within 1 week after discharge home: NP? Outreach for education at staff meetings Bella Terra - done 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 Outpatient pharmacy outreach Medication advocacy for Jardiance, Entresto, Veltassa, Red and Green bag use in clinic

2.2.13. Dr Melonie Atwood, and Tom Denhalter NP Invite to HF committee meetings

2.2.14. Dr. Ashanaki Invite to HF committee meetings

2.2.15. Palliative Care Revive palliative care team 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 Decrease clinic visit time Increase resource utilization Focus clinic visit topics What to include GAD7 PHQ9 QOL What is the questionnaire assessing? Before HF team well being score 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 3 years 2015-2017 in iCentra 2014-2016 in Help 2

4.1.3. Medication reconciliation

4.1.4. Improve use of imaging Accreditation of echocardiogram team Adoption of strain imaging MRI, PET MRI: equipment, proctor & imager DRMC as a HUB of care not a spoke- need resources and equipment to do so Patient access to care Stop sending business and revenue to SLC Decrease threshold for treadmill NM studies

4.1.5. Rural outreach Telemedicine Evidence based HF medicine taken to the rural patient Echo van outreach Cardiomems

4.1.6. -

4.1.7. Patient interactive HF app & Facebook page MAWDS App Wellbeing questionairres Medications: med list, med alarm, medication checklist of pills taken- by picture and name, medication photos, pill identification Activity: pedometer, activity tracker Weight: goal dry weight, enter daily weight, weight graph Diet: daily food entry, track Na+ intake, track fluid intake, recipes- low sodium Symptoms: urine output, weight trend, symptom checklist- instructions based on score, Red/Yellow/Green

4.1.8. Medication titration clinic Protocols

4.1.9. Diuretic/potassium clinic Protocols SR/Obs for urgent diuretic infusion clinic Call CN for approval- if there is staff and a room available, then: give orders, discharge instructions, and if/then orders Already using for albumin infusions for paracentesis, CT hydration

4.1.10. Cardiac/HF medication education campaign Aldosterone blockers

4.1.11. Optimize clinical collaboration with SNF’s

4.1.12. Cardiomems Pays for itself in 1.5 years Rural health

4.1.13. Amyloid

4.1.14. Notebook

4.1.15. Urinals/Hats in clinic

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

4.1.17. Transplant patients in St. George Collaborate with IMC Laboratory testing Notebook copies - electronic version? 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. Collaborate with other facilities

4.1.18. HF clinic services provided? EMR? Home based weight monitoring? Electronic pill box? Hospital discharge transition clinic?

4.2. Inpatient

4.2.1. Increase initiation of inpatient CPAP -

4.2.2. Medication reconciliation Transitions from hospital to SNF Transitions from SNF to home Red / Green bag - all home meds Medication organizer filled for 1 week

4.2.3. Tactical discharge Decrease readmission related to medication reconciliation issues Decrease readmissions related to psychosocial issues associated with HF Decrease readmissions related to fluid volume overload issues associated with HF Hard stop discharge checklist Off IV diuretics for at least 24 hours Pharmacist education No changes to medications in 24 hours Dietitian education

4.2.4. Labs Cystatin C Urine sodium spot check 2 hrs after diuretic dosing Amyloid screening

4.2.5. Fluid volume assessment Fluid Volume Congestion BUN, Creatinine elevated, Cystatin C, Urine sodium, LFT’s elevated 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. 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. Fluid Volume Depletion Labs: BUN, Creatinine elevated, Cystatin C, Urine sodium, LFT’s not elevated-(unless other underlying process) 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. 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