Older adults with heart failure (HF) are particularly vulnerable for rapid changes in condition and hospital readmissions within the first 30 days post discharge, which increases the physical, mental, emotional, and financial cost of caring for all entities (Boxer et al., 2012; Heckman et al., 2017; Heckman, Shamji, et al., 2018; Nazir, Dennis, & Unroe, 2015; Orr, Forman, De Matteis, & Gambassi, 2015). The ability of providers to manage these vulnerabilities and the provision of quality HF care remains elusive in long-term care (LTC) facilities. Evidence suggests the most crucial elements to successful HF management in LTC include staffs' HF knowledge to recognize and intervene in early symptom exacerbations, efficient and effective interprofessional communication with integration in daily care processes, and anticipatory advanced care planning to reduce hospitalizations when risks outweigh benefits (Albert, 2016; Heckman et al., 2016; Heckman, Boscart, & McElvie, 2014; Huckfeldt et al., 2018).
HF is a complex clinical syndrome that results from structural changes and neurohormonal imbalances that impair the heart's ability to pump or eject blood. In the LTC setting, HF affects 20% to 37% of older adults who often have multiple comorbid conditions and frailty (Jurgens et al., 2015; Li et al., 2018). Reports suggest 30-day rehospitalization rates for HF are as high as 43% for individuals discharged to LTC facilities for rehabilitation services (Boxer et al., 2012; Jurgens et al., 2015). Interventions focusing on preventive care are crucial to prevent hospitalization and subsequent irreversible decline in function in vulnerable older adults.
The current article is a condensed and updated version of an evidence-based guideline, Assessing Heart Failure in Long-term Care Facilities, published by the University of Iowa College of Nursing Barbara and Richard Csomay Center for Gerontological Excellence (Harrington, 2019). The full guideline, with graded levels of evidence for assessment, identification of risk factors, recommendations for best practice and interventions, assessment tools, communication tools, a sample lesson plan for staff education, evaluation tools, and quality outcome measures are available in electronic format from http://www.uiowacsomaygeroresources.com. The full guideline also includes the recommended nursing interventions based on the Nursing Interventions Classification (NIC) (Butcher, Bulechek, Dochterman, & Wagner, 2018) and nursing outcomes based on the Nursing Outcomes Classification (NOC) (Moorhead, Swanson, Johnson, & Maas, 2018).
The purpose of the Assessing Heart Failure in Long-Term Care Facilities guideline is to outline a systematic approach to assess individuals at risk for HF, improve LTC facility staffs' ability to recognize early symptoms of worsening HF and mitigate those risks using staff education, interprofessional communication, and a team approach to HF care in LTC, post-acute care, and short-term rehabilitation settings. This evidence-based guideline is intended for use by health care workers in LTC facilities.
Residents at Risk
The identification of individuals at risk for HF is key to reducing potentially avoidable transitions in care settings (Albert, 2016; American Medical Directors Association [AMDA], 2015; Boxer et al., 2012). Residents of LTC facilities with a previous diagnosis of HF with reduced or preserved ejection fraction, coronary artery disease, myocardial ischemia or infarction, valvular heart disease, dysrhythmias (e.g., atrial fibrillation), or cardiomyopathy are at risk for HF hospitalization and would benefit from the implementation of this guideline.
The Minimum Data Set (MDS) 3.0 nurse and administrators might recognize triggers for the guideline in Sections E1A, G1, and G2; Section Ig and Ih; and Section J1 and J5 (Centers for Medicare & Medicaid Services, 2018).
Residents with obstructive sleep apnea, chronic lung disease, poorly controlled thyroid disease (hyper-or hypo-), chronic kidney disease, or increased metabolic demand (anemia, pneumonia, urinary tract infection, fever, or other acute illness) would also benefit from close observation for the development of HF symptoms. Antidepressant agents, psychotropic medication, anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs), or antiplatelet agents have an increased risk for HF (AMDA, 2015; Buntinx et al., 2002; Foebel et al., 2013; Jurgens et al., 2015). Residents taking NSAIDs are at risk for initial or recurrent episodes of HF due to precipitous effects on renal function (sodium retention) and cardiac function (AMDA, 2015; Jurgens et al., 2015; Yancy et al., 2017). Older adult residents who have repeated hospitalizations for either HF or comorbid conditions have higher morbidity and mortality risk as indicated by a Charleson Comorbidity Index score >5 (Figure 1) (AMDA, 2015; Buntinx et al., 2002; Foebel et al., 2013; Huckfeldt et al., 2018; Jurgens et al., 2015; Tamaki et al., 2018).
Algorithm for assessing heart failure in long-term care (LTC) facilities.
Note. CHF = chronic heart failure; SBAR = situation, background, assessment, recommendation; CV = cardiovascular; CNA = certified nursing assistant; NYHA = New York Heart Association; SBP = systolic blood pressure; HTN = hypertension; DM = diabetes mellitus.
Reprinted with permission from Harrington (2019).
Assessment Tools, Instruments, and Forms
Several assessment tools and forms are available to aid in the assessment of patients with HF; however, no available tool meets the specific characteristics of residents in LTC facilities. Descriptions of the major tools are listed in Table 1. The tools and scoring instructions are included in the Appendix of the full guideline (access http://www.uiowacsomaygeroresources.com) (Harrington, 2019).
Assessment Tools for Heart Failure (HF)
Interprofessional Teams in Long-Term Care
LTC interprofessional teams should include the patient and family members, managing practitioners (i.e., physicians, nurse practitioners, physician assistants within the facility), nurses (i.e., Director of Nursing, RNs, licensed practical nurses), certified nursing assistants (CNAs) (i.e., aides), clinical pharmacists, allied health professionals from physical therapy and occupational therapy, social workers, registered dieticians, dietary services, and chaplains. If palliative care teams, geriatricians, or primary care providers outside the facility are involved in the resident's care, they are also valuable members of the interprofessional HF team.
Direct caregivers (i.e., CNAs) provide 80% of the personal care for individuals residing in LTC facilities (U.S. Department of Health and Human Services, 2018). Direct caregivers' observational skills have historically been an underutilized asset in the geriatric workforce; however, there is a large body of outcome evidence that supports their involvement in quality improvement initiatives and care process development (Bryant, Heineman, & Stone, 2008; Casper & O'Rourke, 2011; Heckman et al., 2016; Kim, Ea, Parish, & Levin, 2017; Nazir, Dennis, et al., 2015). For example, in one nurse practitioner–led education HF program for direct caregivers, a 42% reduction in 30-day hospital readmissions was noted over 6 months (Kim et al., 2016).
Description of Practice
The admission assessment using the LTC Heart Failure Assessment tool (Harrington, 2019) provides baseline documentation for individuals who have, or are at risk for, developing HF. The medical records department should be asked to obtain hospital medical records, including echocardiogram results, that are essential to guide the care plan and evaluation measures. Positive findings from either the assessment nurse or MDS form prompt the notification of attending care provider team members using the Situation, Assessment, Background, Recommendation (SBAR) tool that a medical evaluation is needed (Harrington, 2019). The medical evaluation should include confirmation of the diagnosis, risk for rehospitalization, current advanced directives, and the Charleson Comorbidity Index risk score (Buntinx et al., 2002; Jurgens et al., 2015; Tamaki et al., 2018; Yancy et al., 2017). If not completed during the medical evaluation, the goal setting and advanced care plan meeting with the appropriate interprofessional team members, resident, and family members (if desired) is scheduled. Based on the above findings, the interprofessional care team, including direct caregivers, develop and implement an individualized plan of care. The facility should provide all direct caregivers with A NEW LEAF laminated pocket card (Figure 2) (AMDA, 2015; Harrington, 2012, 2019; Harrington & Schoenfelder, 2013; Heckman, Shamji, et al., 2018) to facilitate recognition of vague but relevant observations indicating worsening HF and probable decompensation. The registered dietician should be consulted upon initiation of the guideline. Although a perceived burden among direct caregivers, scheduled weights at the same time of day at least one to three times per week, depending on the resident's medical condition, are crucial to recognize and act on subtle changes in fluid accumulation (Figure 2). The resident's cardiovascular, respiratory, and functional status guide the necessity for SBAR communication and escalation to the treating provider responsible for the resident's care.
Screening tool for direct caregivers.
Disease prevention interventions should include influenza and pneumococcal vaccination, if not contra-indicated, to prevent respiratory and other organ complications that might be detrimental to patients with HF (Black et al., 2017; Isturiz & Webber, 2015; Kim, Riley, Harriman, Hunter, & Bridges, 2017; Moberley, Holden, Tatham, & Andrews, 2013; Tomczyk et al., 2014; Udell et al., 2013).
Weight reduction should be included in the treatment of patients who are obese and have chronic HF (AMDA, 2015; Jurgens et al., 2015). Aerobic and resistance exercise should be encouraged in patients with stable HF within the limits of the severity of disease. In addition, residents should be encouraged to perform activities of daily living and leisure activities that do not induce HF symptoms (AMDA, 2015; Heckman et al., 2016; Jurgens et al., 2015; Nazir & Smucker, 2015).
Goal Setting and Advanced Care Planning
Although the concept of goal setting and advanced care planning is universally accepted as a positive approach to care, time and schedule barriers and the potential for avoidance of difficult conversations might preclude a systematic routine for scheduling and documenting these important discussions (Albert, 2016; Arnett et al., 2017). Although discussions about resuscitation are common (e.g., do not resuscitate), discussions and documentation about the benefits and risks of other interventions, such as preferences in care setting (e.g., treat in place without hospitalization), artificial nutrition (e.g., tube feedings), repetitive use of antibiotics, hydration at the end of life, and comfort measures, provide an opportunity for patient and family concordance and provide clarity for the long-term interprofessional care team (Ersek & Carpenter, 2013; Heckman, Hirdes, et al., 2018; Heckman, Shamji, et al., 2018; Hickman et al., 2011). Resident and family discussions about palliative care options include reducing the burden of symptoms and do not preclude ongoing therapeutic or life-sustaining management as some mistakenly presume. Medical Orders for Scope of Treatment (MOST), Physician Orders for Scope of Treatment (POST), Medical Orders for Life Sustaining Treatment (MOLST), and Physician Orders for Life Sustaining Treatment (POLST) are examples of state-specific orders that transition with the patient between care settings to define and document care preferences and goals (Figure 1) (Heckman, Hirdes, et al., 2018; Heckman, Shamji, et al., 2018).
Goals of care and treatment preference discussions are most optimal when the resident is well and family members are not emotionally distressed by a recent hospitalization. These vital discussions should be scheduled with the family and appropriate members of the interprofessional care team as soon as possible following the confirmation of a HF diagnosis.
Improving Heart Failure Knowledge
Patients and Families. Patient and family education should be provided on topics related to health promotion and disease management (Table 2) (AMDA, 2015; Heckman et al., 2016; Jurgens et al., 2015; Nazir & Smucker, 2015). Patients and families should be taught the rationale for prescriber avoidance of NSAIDs due to their deleterious effects on renal and cardiac function (AMDA, 2015; Foebel et al., 2013). Smoking should always be discouraged and the use of smoking cessation aids, such as nicotine replacement therapies, should be actively encouraged (AMDA, 2015; Foebel et al., 2013; Heckman et al., 2016; Jurgens et al., 2015; Nazir & Smucker, 2015). Consumption of alcohol should also be discouraged in individuals with severe HF (AMDA, 2015; Jurgens et al., 2015; Yancy et al., 2017). Family members should be taught how to read nutrition labels to identify the sodium content in food and drinks. The importance of vaccinations for influenza and pneumonia should be encouraged if not contraindicated. The Heart Failure Society of America (2019) provides educational modules written for the lay person to address relevant health promotion content and encourage an open discussion with the interprofessional team to optimize the patient's desired outcomes. These online resources can be used to supplement face-to-face education sessions for staff, residents with HF, and families.
Heart Failure (HF) Classes for Facility Staff, Direct Caregivers/Certified Nursing Assistants (CNAs), and Family Members
Interprofessional Care Team. The Assessing Heart Failure in Long-Term Care Facilities guideline provides a sample three-class course to support successful guideline implementation and reduction in rehospitalizations (Kim et al., 2017). Each class session is intended to be 20 minutes (Table 2). In Class 1, the instructor reviews a simple description of HF, sodium content in food, three HF management strategies, orientation to the A NEW LEAF pocket card, and the SBAR tool for effective and efficient interprofessional communication. In Class 2, Class 1 content is reviewed and the CNA's role is discussed. Class 3 involves putting it all together, a review of Classes 1 and 2, case scenarios for “What should I do?”, and reiteration of the SBAR tool.
The Assessing Heart Failure in Long-Term Care Facilities practice guideline provides a systematic and interprofessional quality improvement guideline for HF management in LTC, post-acute care, and short-term rehabilitation settings. The guideline outlines opportunities for nursing facilities to identify individuals at risk for rapid cycle rehospitalizations and mitigate those risks using a step-by-step quality improvement process. The evidence-based recommendations are founded on the crucial and often missing components of effective HF management: the stratification of risk on admission, goal setting and advanced care planning, education for patients and family, assessment or observational skills for early recognition, and efficient interprofessional team communication.
Direct caregivers are the most valuable members of the geriatric workforce and provide the majority of care for residents in LTC facilities. Recognition and inclusion of these interprofessional team members in the planning and implementation of any quality improvement process is a key component for successful outcomes.
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Assessment Tools for Heart Failure (HF)a
|LTC Heart Failure Assessment||Developed specifically for use in long-term care (LTC) nursing facilities. The tool comprises two profiles that address three components of activities of daily living and 11 components of dyspnea.|
|Weight graphic||Used to record patient weights. This tool provides a visual guide to recognize weight gain requiring prompt communication and intervention to keep patients' weights within 5 pounds of their baseline weight.|
|“A NEW LEAF” pocket card||Used by direct caregivers to screen for symptoms of HF exacerbation. The pocket card carried by facility nursing assistants serves as a reference for the signs and symptoms of HF exacerbation during routine daily resident care (see Figure 2).|
|SBAR (Situation, Background, Assessment, Recommendation) Interprofessional Team Communication||Includes criteria and triggers specifically for HF to aid nurses in recognizing key assessment components and information the facility care provider team member will need for appropriate determinations.|
|Assessing Heart Failure Outcomes/Chart Audit Form||Provides a tracking mechanism to document quality indicators and outcomes for rapid cycle quality improvement, guideline implementation, and evaluation. Major outcome indicators should be monitored over time and include HF hospitalizations or emergency department visits; transitions to palliative care or hospice; quality of life and functional status on the Minimum Data Set; the number of clinical exacerbations of HF; symptoms management; disease progression; and discharge destination. These outcomes can be adapted to the organization or unit's needs and policies.|
Heart Failure (HF) Classes for Facility Staff, Direct Caregivers/Certified Nursing Assistants (CNAs), and Family Members
|1. Heart Failure: What Is It?||Simple pathophysiology
Sodium content in foods
Three HF management strategies
Daily exercise (aerobic and resistance)
Daily weights (why daily?)
Orientation to a A NEW LEAF pocket card
What is SBAR?
S = Situation (a concise statement of the problem)
B = Background (pertinent and brief information related to the situation)
A = Assessment (analysis and considerations of options—what you found/think)
R = Recommendation (action requested or recommended—what you want)
|Images and pictures with group discussion
Demonstration of HF pathogenesis using plastic bag with liquid and piston syringe
Reading nutrition labels
Fluid weight bottles (examples of one, two, or three liters of water for volume and weight)
|2. HF Signs and Symptoms: The CNA's Role||Review of Class 1 content
Early recognition and reporting makes a difference
HF signs and symptoms
A NEW LEAF
Role of the CNA working with HF patients
Review of discussion of HF patient alert strategies
Health promotion measures
|Images and pictures with group discussion
Gum and sour candy (thirst reduction)
|3. HF: Putting It Together|
Review of Class 1
Review of Class 2
Case scenarios “What Should I Do?”
Reiteration of SBAR
Images and pictures
Group discussion/Family Feud