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2012 CCU Competency


Title: 2012 CCU Competency Author: Karen Marzlin Last modified by: 02411 Created Date: 4/8/2012 4:11:33 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: 2012 CCU Competency

2012 CCU Competency
  • HF Module 2 Nursing Driven Care and Quality

Goals for this module
  • Assessment of dyspnea
  • Volume status
  • Self care management
  • Focus on diet and medications
  • Transitions of care

Assessment of Dyspnea
  • When assessing for dyspnea it is important to
    include the following in your assessment
  • Is your assessment at rest or with exertion?
  • If the assessment is with exertion how much
  • This is why it is important for HF patients to
    participate in Phase I Cardiac Rehab to allow for
    a systematic way to assess activity tolerance.
  • Each step in Phase I Cardiac Rehab is associated
    with a metabolic equivalent of activity which can
    be translated to activities of daily living.
  • It is also important to know if the patient
    becomes dyspneic with minimal exertion such as
    talking or changing positions in the bed.
  • If dyspnea is at rest, it is important to know if
    the patient is dyspneic in the full upright
    position or when lying flat (orthopnea).
  • Congestion is the most common reason for HF
  • Dyspnea is the most common symptom associated
  • Improvement in dyspnea is a primary goal of

Volume Status
  • Many patients who are congested are volume
  • However, it is possible to have pulmonary
    congestion without significant volume overload.
    This often occurs in HF patients who are
    hypertensive. An increase in hydrostatic
    pressure can push fluid out of the vascular space
    and place the patient at risk for flash pulmonary
  • Daily weight and IO are two important tools used
    to assess volume status.
  • The process for accurate IO is already well
    defined through CCU Shared Decision Making and is
    an expectation for everyone.
  • The results of the daily weight should match the
    results of the 24 hour IO. For example A
    negative fluid balance on IO should correspond
    to a decrease in the daily weight.

Volume status
  • Daily weights need to be completed on every
    patient admitted with HF as well as anyone with a
    history of HF (Remember We have instructed
    these patients to weigh daily at home).
  • Always indicate the type of scale used for
    obtaining a daily weight.
  • If the patient is able to stand, a standing scale
    should always be used. This reinforces the
    patients involvement in care.
  • If a bed scale is used, the weight should be done
    with a bottom sheet, one pillow, a pull pad, a
    top sheet, and one blanket only according to
    hospital guidelines. Please remember to
    calibrate the bed before admitting the patient in
    the bed.
  • When a patient is able to be transferred from
    bed weight to scale weight, both weights need to
    be recorded on the day of transition. There will
    always be some variation between the two methods
    and thus both weights need to recorded at the
    time of transition to allow for comparison
    between weights recorded in the same way.

Example Note the inaccurate conclusions that
are drawn when comparing two different scales,
including the difference between a weight loss
and a weight gain.
  • Day 1 Bed Scale 79.9 kg
  • Day 2 Bed Scale 78.3 kg (down 1.6 kg)
  • Day 3 Bed Scale 76.9 kg (down 1.4 kg when
    comparing bed scale to bed scale)
  • Day 3 Standing Scale 75.9 kg (down 2.4 kg
    when comparing bed scale to standing scale)
  • Day 4 Standing Scale 76.3 (up 0.4 kg when
    comparing standing scale to standing scale)

  • (down 0.6 kg when comparing standing scale to
    bed scale)

Sodium Restriction and volume status
  • Except for unusual circumstances the patient
    with HF should be on a sodium restricted diet of
    2 grams of sodium per day. Please advocate for
    your patients by assuring a 2 gram sodium diet is
  • Water follows sodium and the failure to restrict
    sodium can interfere with the ability to
    effectively diurese.
  • HF patients who are hyponatremic are usually
    hyponatremic because they have an excess of free
    water in relationship to normal sodium. The
    treatment is to restrict fluid rather than add
    salt. These patients should also be a sodium
    restricted diet because liberalizing sodium will
    increase the thirst mechanism.

Note Many HF patients are at risk for
hyperkalemia due to renal dysfunction, ACE-I or
ARB, and aldosterone antagonists. These patients
need instructed to avoid salt substitutes that
contain potassium chloride.
Self Care Management
  • Last years competency focused on patient
    education skills related to self care management
  • The self care skills with opportunity for
    improvement included
  • Reliable system to remember to take medications.
  • Ability to read food labels and / recognize
    restaurant foods high in sodium.
  • Home scales with the ability to see and record
    daily weights.
  • Decision making ability to recognize reportable

2012 Focus
  • We want to build on what we learned about self
    care and focus on specific skills we can
    incorporate into practice to support self care.
  • There are three areas of patient education we
    want to focus on for 2012.
  • Documentation of a total of one hour of patient
    education for each heart failure patient.
  • Utilization of HF videos.
  • Involvement of primary caregiver in education
    sessions and discharge instructions.

2012 Focus
  • There are also three specific self care skills we
    want to focus on during 2012.
  • Use of actual food labels when teaching patients
    about a low sodium diet.
  • Medication clarity.
  • Identifying where patients will record daily
    weights and what the patient response will be to
    an increase in weight gain.

Food Labels
  • To assist with patient education of self care
    skills we have created large laminated labels
    that can be used to teach patients how to
    evaluate the sodium content. Two sample labels
    are shown on the next slide.
  • Although we often tell our patients to eat a low
    salt diet, many patients do not have the skills
    necessary to implement a low salt diet into their
    daily lives.
  • Patients need to know that sodium means salt on a
    food label.
  • They also need to know that the amount of sodium
    listed is per serving.
  • A general rule is for patients to eat foods that
    are lt 10 daily value of sodium per serving.

Sample Food labels To Be Enlarged and Laminated
for Patient Education
  • We want to use the SOAR method as a specific
    strategy to improve patient adherence and safety
    with prescribed medications. The SOAR method is
    a method developed specific for CCU competency
    and the HF population.
  • S Stop medications. Please include all
    previous home medications the patient is to stop
    taking as part of the discharge instruction
  • O Over the counter medications. Please
    instruct HF patients not to take any non
    steroidal over the counter medications like
    ibuprofen (Advil) or naproxen (Aleve). These
    medications can contribute to worsening renal
  • A Affordability. Please inform the case
    manager, APN, or physician of any financial
  • R Remember system. Please specifically ask
    the patient / caregiver to identify the system
    they are going to use to remember to take
    medications and remember to take their medication
    list with them to every provider appointment.

Daily Weight Recording and response
  • There are new daily weight log sheets available
    for patients to use.
  • Note Patients should be encouraged to use their
    own system for recording daily weights if they
    already have one.
  • Patients should be instructed to use the first
    weight the morning after discharge as the
    starting weight.
  • Patients need to know to bring a daily weight
    sheet to each physician office visit.

We are going to begin tracking how often patients
bring a daily weight sheets to their first HF
cardiology visit.
Daily weight recording and Response
  • It is also important for patients to know exactly
    what to do if they have a weight gain of gt 2 lbs
    in one day or gt 3 lbs in one week.
  • Patients need to know specifically which
    physician to call for an increase in weight gain.
  • Any patient seen by cardiology should have an
    appointment within one week of discharge.
    Patients should be instructed to call the
    cardiology office for any problems with their
    weight prior to the first follow up visit.
  • If a patient has not been seen by cardiology then
    they should be instructed to call their PCP or
    the physician who routinely manages their HF.
  • Some patients will have instructions to take
    additional diuretic in response to weight gain.
  • These patients will need extra education to
    assure they thoroughly understand how to dose the
    extra diuretic.
  • Taking additional diuretic may require extra
    potassium supplementation and / or more frequent
    lab draws. Please make sure any additional
    requirements are clear to the patient and

General Patient Education Areas for Focus One
Hour of Patient Education
  • One hour of documented HF education
  • This is a new quality indicator for an initiative
    called Target HF which is offered through the
    American Heart Association.
  • The one hour of HF education is a new indicator
    because the study references below showed that
    one hour of nurse education at the time of
    discharge made a difference in patient outcomes.
  • Although we are not looking for one continuous
    time period for the hour of education, we are
    looking for a minimum of one hour total time of
    HF education.
  • Remember this patient population is a high risk
    vulnerable patient population with very special
    education needs.
  • Data collection was imitated in the fall of 2011
    and only 11/180 or 6.1 had a total of hour of HF
  • Our goal is to achieve 85 after everyone has
    completed the competency modules.

Koelling, T. M. , Johnson, M.L., Cody, R.J.,
Aaronson, K.D. (2005). Discharge Education
Improves Clinical Outcomes in Patients With
Chronic Heart Failure, Circulation, 111, 179-185
doi 10.1161/?01.CIR.0000151811.53450.B8
General Patient Education Areas for Focus Video
  • We focused on HF video use during 2011
    competency. Before competency we assessed our
    baseline use of video education in our HF
  • The next slide compares 5 months of pre
    competency video use with the next 5 months after
    we initiated the competency module. As you can
    see there was NO significant improvement.
  • Our goal for 2012 is that 75 our HF patients
    watch at least one HF video. We will share the
    results of this data with you during the annual
    competency meeting.

Remember It is not just showing the HF
education video, you must ask the patients to
teach back what they have learned.
HF Video Use Comparison Data
Heart Failure Video Education Participation Number (1/1 5/31 2011) Participation Number (6/1 10/31 2011) Note 211 HF patients in CCU!
Video 100 HF Treatment Getting Started 26 18
Video 117 Nutrition for HF Patients 17 25
Video 118 Exercise for HF Patients 3 2
Video 119 Understanding HF Medications 1 11
Video 120 Emotions and HF Management 3 0
Video 212 Congestive HF (2nd Ed.) 10 9
General Patient Education Areas for Focus
Education Including Primary Caregiver
  • The primary caregiver is often frail and
    sometimes is not able to frequently visit in the
    hospital (Hospital to Home Initiative). It may
    take a special effort to have them present for
    important information.
  • The primary caregiver is often responsible for
    meal preparation and medication administration.
    For this reason it is important that person is
    identified and involved in the education process.
  • We are asking everyone to do two things when
    educating the HF patient
  • 1) Identify the primary caregiver
  • 2) Assure the primary caregiver is included in
    the education process.
  • This may require a telephone call or discussion
    with other family members in order to get the
    primary caregiver at the bedside for education.

Transitions of care
National transitions of care Coalition
  • Patients Bill of Rights During Transitions of
  • Transitions of care take place each time a
    patient goes from one health care provider or
    health care setting to another. Problems often
    happen during these transitions because
    information is not communicated. Patients and
    their family have the right to care transitions
    that are safe and well coordinated.

Transition of care In HF
  • One important aspect of transitioning care with
    the HF patient is the first office visit post

Follow up Appointment
  • A vulnerable period for readmission is within the
    first week following discharge.
  • For this reason one of the new criteria for the
    American Heart Association Get with the
    Guidelines is for all HF patients to have a
    follow up appointment within one week of
  • To help meet this standard Kathy Evans has been
    working with the CVC APNs and with Colleen Motts
    (Aultmans HF Coordinator) for non CVC patients
    to get an appointment within one week of
  • It is important that the provider, date and time
    be listed in the discharge instructions. It is
    not acceptable to say Call Dr. _______ for an
    appointment in one week..

Our Success with one week appointments
  • Initial Aultman Hospital data collected in 2011
    showed 28 of 103 patients or 27.2 of HF patients
    had a discharge appointment within one week of
  • January 2012 data showed that 39/84 or 46.4 of
    HF had a discharge appointment within one week of
  • There has been an improvement but we are not yet
    where we need to be.
  • If you are discharging a HF patient that is being
    seen by CVC (admitting or consulting) and there
    is not an appointment (date, time, and provider)
    for within one week of discharge please call the
    APN who is covering your POD.
  • If the patient is not being seen by CVC you can
    discuss with the discharging physician or page
    the HF nurse.

CVC Follow Up Appointments
  • HF patients being seen by a CVC cardiologist
    during their hospital stay will have their one
    week follow up appointment made in the HF clinic
    within the CVC office.
  • The HF clinic appointments are with an advanced
    practice nurse (APN) or physician assistant (PA)
    within the CVC practice. The APN and PA have
    access to a cardiologist during the HF clinic
    appointment if needed.
  • The most current data from the HF clinic show
    that 40 of the one week HF appointments are no

CVC Follow Up Appointments
  • When discharging a HF CVC patient with a one week
    appointment, it is important to be accurate about
    whom the follow up appointment is with. The
    names of the APN or PA should be circled or
    written on the appointment card.
  • Also please stress with the patient the
    importance of keeping this first one week
    appointment (even if it is within a day or two
    after discharge).
  • During this appointment the next appointment with
    the cardiologist will be made.
  • Additionally, a report will be sent to the
    primary care physician communicating all aspects
    of HF care.

Special Instruction regarding first HF clinic
  • There will be a one page handout to give to
    patients along with their appointment card, that
    describes the purpose of the first HF visit.
  • Please instruct patients and families to bring
    all their prescription and over the counter
    medications in a plastic or brown paper bag to
    their HF clinic appointment.
  • An important aspect of this first visit will be
    to review all patient medications.

FYI New HF Certification
  • For anyone who might be interested there is a
    new heart failure certification exam for nurses
    offered by the American Association of Heart
    Failure Nurses.
  • To be eligible for this certification a nurse
    must first have 30 hours of continuing education
    in heart failure to be eligible for
  • You do not need to have a CCRN or PCCN
    certification to sit for the heart failure
    certification exam.
  • If interested check out the following website

We must not, in trying to think about how we can
make a big difference, ignore the small daily
differences we can make which, overtime, add up
to big differences that we often cannot
foresee. -Marian Wright Edelman
To Complete this module
  • To complete this module please bring examples of
    the following to your annual competency meeting.
    Please include these examples in your
    professional portfolio.
  • Bring an example(s) of patient self care
    education you were involved in specific to a)
    label reading for sodium, b) the SOAR method for
    medication adherence and compliance, or 3)
    instruction regarding recording and response to
    daily weights.
  • Bring an example(s) of how you have supported a)
    involvement of the primary care giver, b)
    documentation of one hour of patient education,
    or c) viewing and teaching back of the HF videos.

Your Choice Activity Choose One of the
Activities to the Left. (your choice activity
will be discussed at your competency meeting).
  • Obtain or maintain certification as a CCRN, and
    / or CMC, or HF certified nurse.
  • Submit a peer review written statement or a self
    reflective written statement (in your portfolio)
    demonstrating how you have shown clinical
    leadership in the area of teaching patients self
    care skills related to low sodium diet,
    medication adherence and safety, and or daily
    weight recording and reporting as discussed in
    this module.
  • Read an evidence based patient education journal
    article on heart failure management identify
    how this article will change your practice and
    bring to your individual competency meeting.
  • Volunteer to serve on the Heart Center HF Work
    Group. Let Rhonda know if you are interested.

Literature supports that professional nurses
should take ownership in validating their own
competency. Source National Education
Framework Cancer Nursing, 2008
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