| |
Brigitte Lindsay RN, NP, MN (Hons)
Heart failure is a major medical problem which adversely impacts on many lives. It accounts for 1% of the annual health budget, approximately $NZ50 million in 1994 (Doughty, Yee, Sharpe, & MacMahon, 1995). The cost is likely to be higher today due to inflation and because admission rates for heart failure have risen by 10.6% over the last five years (National Heart Foundation of Zealand, 2004).
Numerous trials have demonstrated the significant benefits of heart failure clinics in terms of patient outcomes and cost-savings (Askosah, Schaper, Havlik, Barnhart, & Devine, 2002; Blue et al., 2001; Cline, Israelsson, Willenheimer, Broms, & Erhardt, 1998; Coats et al., 2002; R. N. Doughty et al., 2002; Funrow, Stevenson, & Walden, 1997; Rich et al., 1995). The Cardiac Society of Australia and New Zealand Heart Failure and the American College of Cardiology/American Heart Association Guidelines state; “nurse-led multidisciplinary programs of care targeting high-risk CHF patients following acute hospitalisation prolong survival, improve quality of life, and are cost effective in reducing recurrent hospital admissions and advocate their use (level one evidence)” (Hunt et al., 2005; Krum H et al., 2006). There is evidence to show that heart failure specialist involvement in heart failure clinics is imperative to achieve the best outcomes (Davidson et al., 2001; Grady et al., 2000). The successful community programmes have been based under the cardiology speciality in secondary care but with out-reach into the community by at least one home-based visit for high risk patients (Clark & Mc Murray, 2001; Hunt et al., 2005; Stewart & Blue, 2004). Nurse Practitioners have the ability to be highly effective members of the health care team (Nursing Council of New Zealand, 2002, 2004).
With this body of evidence and the results from the Hawera heart failure clinic, a year- long pilot project, the Community Heart Failure Clinic, is currently under way. I am currently only funded as a Cardiac Failure Nurse Practitioner for three days a week for one year. I also work one day a week in South Taranaki as a Cardiac Clinical Nurse Specialist (Cardiac Rehabilitation, Phase II). I am also employed casually by the local Polytech (WITT) as a clinical supervisor for nursing students. I hope that in the future I will be funded to provide Cardiac Nurse Practitioner care for other cardiac patients, not just those with heart failure as I am registered to care for all adult cardiac patients.
As the Cardiac Failure Nurse Practitioner I work across the health continuum in Taranaki. The role is run and funded under the TDHB umbrella. My prescribing rights in cardiology allow for the service to be run autonomously while still maintaining strong links with the cardiologists, the Primary Health Care Sector and other members of the multi-disciplinary team.
In order to improve patient access some of my clinics are run in areas where patients often have difficulty accessing the main hospital service. One such place is Waitara which has a larger Maori population and more people of poorer socioeconomic status. The health centre is run by local GPs but with clinic space for hospital health workers. This set up helps with integration of the primary and secondary health care services. Another clinic is run out of a GP practice in the New Plymouth area as an attempt to promote closer liaison with general practice. All patients in the area can attend the clinic even if their GP is not from that particular practice. Patients are not charged for visits. I am currently looking at opportunities to work more closely with the practice nurses as well. I make every effort to ensure GPs are informed about the consultations I have with their patients to work collaboratively with them. I also work out of the satellite hospitals in South and Central Taranaki. In addition, I run clinics in the cardiology suite in Taranaki Base Hospital.
It is vital not to work in isolation especially as a new prescriber. I have clinical support from the cardiologists and some clinics I run in the hospital setting are in parallel to theirs so I can call on them for their advice if need be. Otherwise we communicate by email or telephone. We have set up regular meetings for case review. I have support from the other hospital physicians. Networking with my nursing colleagues is also vital.
As my patients are highly complex with multiple co-morbidities, managing them can be tough and challenging but also very rewarding when you see you are making a difference for these patients and their families. I sometimes think “ now, what do I do with this patient?” and need to draw deeply on my cardiology experience and critical thinking. However, I take reassurance in that if the patient problems extend me too much, I know I can refer on or seek advice. I may identify other non-cardiac issues which I then refer back to their GP or appropriate specialist/health professional. On the other hand it is great being able to see with clarity something that needs doing and having the autonomy to go and do it.
My role allows for closer monitoring and follow up which is difficult to achieve in primary care and within the Cardiology clinics. In this way titration of medication can occur more slowly and as a result there is more success at reaching recommended therapeutic doses of heart failure medication. Frequent follow up provides more opportunity to promote self-management, for counselling and more in-depth conversations which often reveal other underlying issues that need addressing.
Aside from the clinical role, I am frequently consulted on various other matters such as health projects, reviews, protocols, patient education material, and clinical pathways. I also provide both formal and informal teaching to other nurses.
As a nurse practitioner I am involved in research. Currently this includes participation in the National Heart Failure Registry and in the future I am looking at auditing of several NZ nurse led heart failure clinics in conjunction with the New Zealand Heart Failure Group. I also want to evaluate a diuretic self titration protocol I designed.
The road to becoming a Nurse Practitioner was fuelled by passion and a belief I could make a positive difference in an extended role. It was a long hard journey but worth it in the end. Importantly, if it was not for the support of many people - our cardiologists, nursing colleagues, GPs, hospital managers, funding and planning team and of course, my family - I would not have been able to get to this point. Having funding from the hospital and Ministry of Health for my studies and then being able to get guidance from the Nurse Practitioner Advisory Committee of NZ to put together my portfolio were also important factors in a successful outcome. I am very appreciative of all the help I had. For those wanting to take this path I say, “keep your vision in mind to spur you on and take all the support you can get along the way”. Believe that you can make a difference because nurses can.
Akosah, K. O., Schaper, A. M., Havlik, P., Barnhart, S., & Devine, S. (2002). Improving care for patients with chronic heart failure in the community. The importance of disease management. Chest, 122, 906-912.
Blue, L., Lang, E., McMurray, J. J. V., Davie, A. P., McDonagh, T. A., Murdoch, D. R., et al. (2001). Randomised controlled trial of specialist nurse intervention in heart failure. British Medical Journal, 323, 715-718.
British Heart Foundation. (2002). Factfile 09/2000. Nurse-led, home-based management of chronic heart failure. Retrieved December 17, 2004, from www.bhf.org.uk/factfiles/
Clark, A. L., & Mc Murray, J. J. V. (2001). Heart failure. Diagnosis and management. London: Martin Dunitz.
Cline, C. M. J., Israelsson, B. Y. A., Willenheimer, R. B., Broms, K., & Erhardt, L. R. (1998). Cost effective management programme for heart failure reduces hospitalisation. Retrieved January 1, 2002, from http://heart.bmjjournals.com/cgi/content/full/80/5/442?maxtoshow=&HITS=10&RES...
Coats, A., Cowie, M. R., Davies, M., Elliot, P., Frenneaux, M., Gibbs, S., et al. (2002). Delivering evidenced-based care to patients with heart failure: Results of a structured program. British Journal of Cardiology, 9(3), 171-179.
Davidson, P., Stewart, S., Elliot, D., Daly, J., Sindone, A., & Cockburn, J. (2001). Addressing the burden of heart failure in Australia: the scope for home-based interventions. Journal of cardiovascular Nursing, 16(1), 56-69.
Doughty, R., Yee, T., Sharpe, N., & MacMahon, S. (1995). Hospital admissions and deaths due to congestive heart failure in New Zealand 1988-1991. New Zealand Medical Journal, 108, 473-475.
Doughty, R. N., Wright, S. P., Pearl, A., Walsh, H. J., Muncaster, S., Whalley, G. A., et al. (2002). Randomized, controlled trial of integrated heart failure management. The Auckland heart failure management study. European Heart Journal, 23, 139-146.
Funrow, G. C., Stevenson, L. W., & Walden, J. A. (1997). Impact of a comprehensive heart failure management program on hospital admission and functional status of patients with advanced heart failure. Journal of American College of Cardiology, 30, 725-732.
Grady, K. L., Dracup, K., Kennedy, G., Moser, D. K., Piano, M., Warner Stevenson, L., et al. (2000). Team management of patients with heart failure: A statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association. Circulation, 102, 2443-2456.
Hershenberger, R. E., Hanyu, N., Nauman, D. J., Burgess, D., Toy, W., Wie, K., et al. (2001). Prospective evaluation of an outpatient heart failure management program. Journal of Cardiac Failure, 7(1), 64-74.
Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiants, T. G., et al. (2005). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult - summary article. Circulation, 112.
Krum H, Jelinek M, Stewart S, Sindone A, Atherton J, Hawkes A, et al. (2006). Guidelines for the Prevention, Detection and Management of
People with Chronic Heart Failure in Australia. Retrieved 27 May, 2007, from http://www.csanz.edu.au/guidelines/practice/Chronic_Heart_Failure_guidelines_061106.pdf
National Heart Foundation of Zealand. (2004). Heart failure. Retrieved November 29, 2005, from http://www.nhf.org.nz/index.asp?pageID=2145822564
Nursing Council of New Zealand. (2002). The Nurse Practitioner. Responding to health needs in New Zealand. Retrieved July 16, 2004, from http://www.nursingcouncil.org.nz/nursepractitioner.html
Nursing Council of New Zealand. (2004). Ministry of Health and Nursing Council Launch of Nurse Practioner™ . General Information. Retrieved July 16, 2004, from http://www.nursingcouncil.org.nz/nursepractitioner.html#general
Rich, M. W. R., Beckham, V., Wittenberg, C., Leven, C. L., Freedland, K. E., & Carney, R. M. (1995). A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. New England Journal of Medicine, 333, 1190-1195.
Stewart, S., & Blue, L. (2004). Improving outcomes in chronic heart failure; Specialist nurse intervention from research to practice (2nd ed.). London: BMJ Publishing Group.
Stewart, S., Blue, L., Walker, A., Morrison, C., & Mc Murray, J. J. V. (2002). An economic analysis of specialist heart failure nurse management in the U.K. European Heart Journal, 23, 1369-1378.
CRITERIA FOR REFERRALS TO
CARDIAC FAILURE NURSE PRACTITIONER
- Patients with significant heart failure as primary diagnosis or as an active problem.
- Patients with two or more admissions with heart failure in the past year.
- Inpatients for early discharge for early follow up at the Heart Failure Clinics or in the community. Emphasis on patient education, treatment optimisation, and compliance monitoring.
- Patients referred by general practitioner (or other sources), with significant problems in relation to heart failure. Emphasis on patients who are deteriorating in the community for whom same day/next day review may well avoid admission.
- Patients initially triaged from ED or discharged from CCU, with admission avoided by early review at the Heart Failure Clinic, or early intervention in the community.
When prioritising patients factors that place them at higher risk will be considered i.e.
- Elderly
- Multiple co-morbidities
- Frequent flyers
- Maori
- Low socioeconomic status
- Living in isolation
- Patients (and families) whose medical care suffers because of educational deficits, or patients with compliance issues.
ROLE OF A CARDIAC FAILURE NURSE PRACTITIONER
A specialist in cardiology, the Cardiac Failure Nurse Practitioner closely monitors heart failure patients allowing for careful up-titration of heart failure medications to recommended doses. She institutes non-pharmacological interventions and the promotion of self-management. By working within the multi-disciplinary team with an awareness of the wider determinants of health allows for a broader approach to the health of cardiac patients to be adopted. With her expertise she is able to act as a consultant and educator for other health team members. She participates in research and contributes to local, national and sometimes international policy,
ACTIVITIES INCLUDE:
- Monitoring of blood chemistry
- Ordering and interpretation of special tests and investigations
- Liaison with clinical personnel
- Optimisation medication regimes (prescribing cardiac medications)
- Consultation with specialist personnel (e.g. cardiologist)
- Referral to appropriate personnel for issues out of area of practice
- Promotion of self-management
- Education & counselling for patient and family – behaviour strategies
- Involve Maori e.g. clinics/education sessions at monthly Kaumatua days
- Provide at least one prolonged home visit for high risk, complex patients if indicated
- Admin - pt notes, referral letters etc
- Education and support for clinical staff
- Writing of guidelines/protocols
- Provide support for patient groups -facilitate development of expert patient role
- Address barriers to access and adherence
- Develop strategies to target disadvantaged
- Develop/maintain expertise - clinical supervision , attendance conferences, networking, study
- Auditing/monitoring and help with future planning of service
- Involvement in research (could be part of auditing)
- Facilitate intra and inter-sectoral collaboration
|
