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Army Embraces Nurse-Run Clinic

Monday July 28, 2003
From left, nurse practitioner Stacy Walsh, RN; Col. Marina Vernalis, MD; and nurse practitioner Cathy Franklin dramatically improve outcomes for patients with heart failure at Walter Reed Army Medical Center in Washington, DC. 
Photo by Winston S. Wilson.
From left, nurse practitioner Stacy Walsh, RN; Col. Marina Vernalis, MD; and nurse practitioner Cathy Franklin dramatically improve outcomes for patients with heart failure at Walter Reed Army Medical Center in Washington, DC. Photo by Winston S. Wilson.
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When nurse practitioner Cathy Franklin helped launch Walter Reed Army Medical Center's first NP-run clinic, her biggest challenge was convincing cardiologists to send their advanced heart-failure patients to her for care.
Three years later, cardiologists at the Army's premier hospital in Washington, DC, no longer need convincing. In fact, in June the heart-failure clinic and five other disease-specific management programs were certified by the Joint Commission on Accreditation of Health Care Organizations (JCAHO).
They are six of only 15 such programs to be awarded the certification since it was first offered about a year ago, says Charlene Hill, a spokeswoman for JCAHO.
In addition to that achievement, the clinics were the first disease management programs in the Department of Defense to be given the nod by JCAHO, says Army Col. Marina Vernalis, MD, chief of cardiology at Walter Reed.
In addition to the heart-failure clinic, also approved were management programs for pediatric asthma, women's healthcare, coronary risk reduction, diabetes, and chronic obstructive pulmonary disease.
Franklin runs the heart-failure clinic with civilian NP Stacy Walsh. Together they monitor the health of approximately 250 patients with class III and IV heart failure. All of their patients are US veterans, the majority are men, and their average age is 65 to 80 years.
The clinic's monthly outcome studies show 100% of its patients are on medications, hospital admissions among this group of patients have decreased 40%, and ED visits have dropped by 50%, says Franklin.
The results of the outcome studies validate the clinic's effectiveness and help guarantee physicians no longer question the value of the clinic, says Vernalis, who helped launch the clinic with Franklin.
"I believe the physicians in our healthcare system are delighted to have the clinic," she says. "The heart failure clinic is a successful model of care. "We now have a track record of improved clinical outcomes on more than 220 patients with advanced heart failure."
Individuals with class IV heart failure have difficulty performing activities of daily living because they experience symptoms such as dyspnea, fatigue, fluid retention, and peripheral edema. People with class III heart failure have such symptoms with minimal exertion.
These are the patients who need to be closely monitored, says Franklin, who is a civilian nurse. Initially, individuals come to the clinic to receive education about their condition, diet, medications, exercise, and self-weight monitoring. They are also placed on the appropriate medication, and dosages are titrated to the appropriate levels.
Patients are prescribed basic cardiac medications - ACE inhibitors, beta-blockers, and aldactone. In addition, they are given Digoxin and Lasix, as needed.
Once patients are receiving and tolerating the proper doses of medications, they visit the clinic less often, about every four weeks. With the correct medications and follow-up, patients can experience a dramatic improvement in the way they feel and the quality of their lives. One of Franklin's patients was a 78-year-old man who was caring for his paraplegic son. The man went into class IV heart failure and developed so many symptoms he could no longer take care of his son.
The patient began taking medication and received a biventricular pacemaker. "He felt so much better," says Franklin. "And he was able to resume caring for his son."
Because of the frequency and the consistent, long-term care the two NPs provide, Franklin and Walsh become dependable resources for their patients and develop close relationships with them. "They love having someone to call with their questions," says Franklin.
Jim Jones, a heart-failure clinic patient, says of Franklin, "She's so compassionate. At some places you are just a piece of meat. Cathy's one of the best people I've ever met."
Jones, 65, has been visiting the clinic for three years. He said when he started going there, he had significant edema and was not doing well. "The clinic got me stabilized and stopped my rapid heartbeat," he says.
Walsh receives daily calls from the wife of a former clinic patient who died. "She calls every morning, and it's been almost a year now since her husband died," she says. "It's support for her. You develop a rapport with these patients and their families."
Janet Boivin, RN, is editorial director of Nursing Spectrum.