Catawba Valley Hospice Adds Cardiac Support
Monday July 14, 2008
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"We began to collect data and ... found out that we were below the national average in the number of patients served with heart failure. Across the nation, 11% of hospice patients have a primary diagnosis of heart failure; our census only consisted of 9.5% of patients with heart failure," says Julie Packer, RN, MSN, physician liaison at the center.
By 2006, the hospice had extensively trained their palliative care and hospice nurses and developed protocols for the specific needs of heart-failure patients.
The census of heart-failure patients at the center increased to 12.7% of the hospice's population in the first nine months of the program. In the nine months before starting the heart-failure program, 30% of its heart-failure patients were rehospitalized. That percentage dropped to 21% in the nine months after and continues to fall, according to Packer.
A bumpy ride
While hospices and palliative care centers generally accept heart-failure patients, there are only a few programs around the country that focus on these patients' special care needs, according to Packer. Even referring doctors and nurses often don't understand how these patients fit under the end-of-life umbrella.
"There are differences in end-of-life with heart failure versus end-of-life in cancer," says Sara Paul, RN, MSN, FNP, director of the heart-function clinic at Western Piedmont Heart Center, Hickory, N.C., and the nurse practitioner who educated nurses at the Newton facility about end-of-life care for these patients. "The cancer death trajectory is straight — a straight, slow, downhill decline until death. With heart failure, there are lots of bumps. It's like a rollercoaster ride. There are times when [patients] are worse and you give them a little bit of treatment and they get better, then worse, then better. All the while, each time they get better it's not to the same level that they were at before."
The care nurses provide these patients in palliative care and hospice settings is also different, according to Packer. "There may be a presumption that when patients come to hospice, generally medications are stopped and the technology becomes less tech and more high touch, but in this group of patients ... we're stepping up efforts. We see these patients more often to prevent hospitalization; we do not discontinue medications for their cardiac diagnosis and, in fact, maintain many of them because they provide symptom management; and we very aggressively instruct patients in their diet compliance, adhering to a low-salt diet. We weigh them regularly. We also do not discharge them during periods of stability," Packer says.
Nurses in the program learned, through hands-on shadowing with Paul, how to assess heart-failure patients and treat symptoms that might have otherwise sent them to the ED and resulted in their hospital admission.
Sharp skills needed
The nurses improved on skills they rarely use with end-stage cancer patients, according to Lisa Johnson, RN, BSN, CHPN, director of professional development at Palliative CareCenter in Newton.
"Sometimes hospice nurses working with end-stage patients are not doing a lot of IV therapy," Johnson says. "Those skills have to be sharpened because the medications [for heart-failure patients] are typically IV medications. They also need education on specific medications used. .... We have an algorithm that we go by, with protocols for medication administration."
According to Johnson, many heart-failure patients do not qualify for traditional home health care because they might be stable when they are evaluated for the service. "But when they plummet and go into heart failure, they're very sick. So we're able to go in through hospice and palliative care and pick up this piece that home health cannot provide for these patients," Johnson says.
Heart failure patients, according to Packer, are admitted under the hospice Medicare or Medicaid benefit. Patients who qualify are generally in end-stage 3 or 4 heart failure, have symptoms with minimal exertion or at rest, have maximized their use of medications for their cardiac condition, and have an ejection fraction of 20% or less.
"It's one area [in which nurses] can play a very critical role in the active treatment of the disease and, in treating the disease, still be providing comfort care," says William Thompson, MD, medical director, Palliative CareCenter.
Lisette Hilton is a freelance writer.
To comment, e-mail editorSE@nursingspectrum.com.
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