When thinking of heart failure, a character who may come to mind is “Denny Duquette,” a heart transplant patient on the TV series “Grey’s Anatomy.” After many plot twists over many episodes — during which he stole the hearts of viewers and of surgeon Isobel “Izzie” Stevens — Denny received a new heart for his serious heart failure. But Denny did not survive the immediate postsurgical period. This may have very well led viewers to think that heart failure begins and ends with dramatic measures, such as surgery.

In reality, heart failure begins insidiously. In the initial stage, a patient has cardiovascular risk factors, such as hypertension, diabetes, obesity, or atherosclerotic disease, but no presenting signs and symptoms. The first real introduction to heart failure’s four stages often comes later — once patients have experienced a cardiac event, such as an MI or development of a nonischemic cardiomyopathy. Later, the heart undergoes structural changes, and heart failure symptoms begin. This can be an overwhelming time for patients and families as they cope with the challenges of managing a heart ailment that, gone uncorrected, has a progressively worsening course.

Another stage of patient can present with the classic heart failure symptoms of peripheral edema, dyspnea, and orthopnea. These signs of decompensated heart failure, whether brought on suddenly or occurring slowly over time, require initiation of heart failure therapies or a change in course of existing ones.¹

Heart failure is a problem of staggering proportions, affecting 5 million people in the United States, with people over age 65 facing a one in a hundred chance of a heart failure diagnosis. About 550,000 Americans each year are newly diagnosed with heart failure.¹ And as more than 1 million people are admitted to or discharged from the hospital with diagnoses of heart failure, this equates to a bill of $33.2 billion per year in direct and indirect costs for the United States and makes treating heart failure the largest expense for Medicare.¹

The Joint Commission has stepped forward to guide healthcare organizations in managing heart failure. Nurses’ knowledge of Joint Commission heart failure core measures, usual heart failure presentations, and evidence-based guidelines for diagnosis and treatment can make a positive impact on the lives of patients and their families — and the community at large.^2,3

Heart failure is a clinical syndrome derived from a structural or functional cardiac disorder that impedes the ability of the heart’s ventricle to eject or fill with blood. ¹ Heart failure may be classified as acute or chronic, ischemic or nonischemic, or simply left- or right-sided. Common subclassifications are 1) a left ventricular systolic (LVS) or ejection fraction disorder and 2) a left ventricular diastolic or filling disorder.¹

The risks

Major risk factors include hypertension, diabetes, metabolic syndrome, dyslipidemia, established atherosclerosis, obesity, sleep apnea, and a family history of cardiomyopathies. Women are becoming increasingly aware of their risks of heart disease, and for women with established coronary heart disease, diabetes is the strongest risk factor for predicting heart failure. Women with coronary heart disease and diabetes develop heart failure at a rate of 3% per year if they have no additional risk factors and at a rate of up to 8.2% per year if they have three additional risk factors.⁴

Smoking and a sedentary lifestyle, along with any compounding depression and chronic stress, can increase a person’s chance of developing heart failure. Medical causes of heart failure typically include cardiovascular disease, especially a history of myocardial infarction, valvular disorders, or viral myocarditis; cardiotoxins, especially alcohol; and comorbidities such as thyroid disorders, collagen disease, pheochromocytoma, rheumatic fever, or radiation therapy to the chest.⁴ These serious disorders lead to a heart failure mortality rate within eight years of a diagnosis of heart failure of about 80% for men and 70% for women.² Even more disconcerting is that the incidence of sudden cardiac death in this cohort is six to nine times higher than the rate in the general population.² The encouraging news is that evidence-based practice guidelines and technologic advances in treatment have increased survival time.

What goes wrong

With knowledge of the basic pathophysiology of heart failure, nurses can better understand the rationale for treatment modalities and for The Joint Commission’s heart failure core measures. With systolic heart failure, significant ventricular remodeling occurs, leading to hypertrophy of cardiac muscle, cellular dysfunction, hemodynamic and chemical changes, impaired ejection fraction, and an elevation of ventricular filling pressures. Diastolic heart failure presents with impaired LV relaxation and chamber filling, plus overall LV stiffness. Systemic changes are both hemodynamic and neurohormonal involving renin-angiotensin system alterations in the kidney. Characteristically there is a release of catecholamines (e.g., epinephrine) that increases heart rate and myocardial oxygen demand, vasoconstriction of the arterial and venous beds, and fluid retention as a compensatory response. These changes become evident in the skeletal muscle; the renal, pulmonary, GI, and neurologic systems; and the inflammatory response.⁵

While performing the physical assessment, the nurse should look for classic signs of heart failure, such as swelling or edema of the legs, feet, or abdomen (ascites); dyspnea; orthopnea; crackles on lung auscultation; extra heart sounds on cardiac auscultation (an S3 or S4 gallop); jugular venous distention (JVD); hepatomegaly; and a positive hepatojugular reflex. The patient may have hypo- or hypertension, orthostatic blood pressure changes, skin pallor, and diaphoresis. The nurse must be alert to and report dyspnea, orthopnea, paroxysmal nocturnal dyspnea, weight gain, fatigue or generalized weakness, cough, palpitations, sleep apnea, or vague complaints of insomnia. Not uncommon are complaints of anxiety, chest pain or anginal equivalent, confusion, or decreased appetite, especially when paired with abdominal bloating or hepatic engorgement.^1,6

Diagnostic tests include an ECG to look for signs of ischemia and conduction system disturbances and a chest X-ray to view for the presence of pulmonary edema, pleural effusions, an enlarged heart, or Kerley B lines, white lines on a chest X-ray running perpendicular to the base of the lungs. Kerley B lines are an early indicator of lung congestion and reflect fluid in the interlobular areas.⁶

From the lab

Laboratory tests include brain natriuretic peptide (BNP), a hormonal-like substance released by a volume- overloaded heart; CBC; electrolytes; blood urea nitrogen (BUN); creatinine; fasting blood glucose; lipid profile; liver function tests; thyroid stimulating hormone; and urinalysis. Underlying disorders, such as diabetes and chronic renal failure, may be noted in standard tests. BNP testing is fairly new and deserves special attention as a test reflecting myocardial stretch and volume overload. BNP levels greater than 100 pg/mL when accompanied by classic heart failure symptoms have 90% sensitivity and 76% specificity to help distinguish heart failure from other disorders that cause dyspnea.

Finally, visual analysis of LVS function, or ejection fraction, and valvular flow is usually possible with an echocardiogram (the most common test) or a multiple gated acquisition scan (a nuclear test that evaluates the heart’s ventricles). Advanced hemodynamics is generally indicated in the acutely ill heart failure patient combating cardiogenic shock and other severe clinical states.⁶

Heart failure is a symptomatic and progressive disorder as evidenced by the American College of Cardiology (ACC) and American Heart Association (AHA) classifications of stages of its development. Grading via the subjective New York Heart Association (NYHA) Functional Classification system can place the patient on a continuum of improvement or decline. These classifications guide treatment decisions and nursing practice.^5,7,8

Nursing care for patients with heart failure calls for the ability to detect problems, manage changing clinical presentations, and take measures to correct decreased cardiac output, alterations in respiratory status, volume excess, and any limitations self-care management. One way to guide patients with heart failure through treatment is with collaboratively developed critical pathways that prepare patients for the mandated core measures at discharge. The goal is patient self-care, or family care, which calls for dietary and sodium restrictions, daily weights, and the monitoring of medications, symptoms, and activity. Medication monitoring is a complex issue that must address the patient’s adherence to heart failure medications and restrictions on alcohol and NSAIDs.

The management of coexisting diseases and general conditioning via exercise prescriptions enhance patients’ ability to use their physical resources to combat progressive heart failure. For example, guided exercise programs have proved to help people with depression, a common comorbidity with heart failure.^4,5

The core four

The Joint Commission works to improve patient care through accreditation and performance improvement measures in healthcare settings.⁹ For example, Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2007 (available at www.jointcommissionreport.org) profiles performance measures for heart attack, heart failure, pneumonia, and surgical infection.⁹ To specifically address heart failure, The Joint Commission’s Heart Failure National Quality Measures mandate that four core measures be met on every patient 100% of the time with few exceptions.⁹ (The Centers for Medicare and Medicaid Services, the AHA, and the ACC are collaborating with The Joint Commission on this initiative.) The four heart failure core measures are as follows:

• HF-1: Discharge instructions. Written discharge instructions reduce nonadherence and must address activity level, diet, all discharge medications, follow-up appointments, weight monitoring, and measures to take if symptoms worsen. Site practice suggestions include a cross reference of medications and a validation of discharge instructions in the medical record.
• HF-2: An evaluation of LVS function. This LVS functional  assessment occurs before hospital arrival or during the hospital stay or is planned at the time of discharge.
• HF-3: Angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker for LVS dysfunction. ACEI and ARB have been shown to decrease mortality and morbidity in heart failure patients with accompanying LVS dysfunction. Contraindications to ordering an ACEI or ARB include a documented allergy to either drug, angioedema, hyperkalemia, hypotension, renal artery stenosis, worsening renal function, severe renal disease or impaired renal baseline function, and moderate or severe aortic stenosis. The use of ACEI or ARB at hospital discharge has been associated with a reduction in rehospitalizations and mortality. Clinical trial data indicate that beta blockers prescribed at discharge are also associated with improved outcomes, but The Joint Commission has yet to adopt the use of beta blockers as a core measure.¹⁰
• HF-4: Adult smoking cessation advice/counseling. Stopping smoking decreases mortality and morbidity across disease states. Patients are much more likely to quit smoking if they receive counseling on its hazards.

These core measures are intended for patients with a principal diagnosis of heart failure and a discharge to home or home care services. They are not appropriate for patients younger than 18, patients enrolled in clinical trials, patients who have a documented and Joint Commission-accepted reason for no evaluation of LVS function or institution of an ACE1 or ARB (such as intolerance of these drugs), patients with orders for comfort measures only or who are being discharged to hospice (typically those categorized as ACC/AHA Stage D and NYHA Class IV heart failure patients), patients who have had a heart transplant or left ventricular assist device implanted during the reviewed hospitalization, and patients who leave against medical advice or are transferred to another acute care facility.⁹

How are we doing?

Adherence among hospitals to the Joint Commission core measures was 59.7 % in 2002, and in 2006 compliance increased to 84.1%, a 24.4% improvement.⁹ Statistics for adherence to individual measures are as follows:⁹

• Providing discharge instructions: 30.9% (2002) and 70.3% (2006), a 39.4% improvement.
• Providing LVS assessment: 81.5% (2002) and 93.4% (2006), an 11.9% improvement
• Prescribing an ACEI or ARB at discharge: 74.2% (2002) and 85.6% (2006), an 11.4% improvement.
• Providing smoking cessation advice: 42.2% (2002) and 92.1% (2006), a 49.9% improvement.

As the percentages show, the core measure of providing discharge instructions remains a challenge for most hospitals, and reports from The Joint Commission on overall adherence can be the starting point for a hospital’s improvement efforts.⁹ Each hospital’s Joint Commission report is available at www.qualitycheck.org.

ACC/AHA 2005 Clinical Performance Measures for Adults with Chronic Heart Failure, a document similar to the core measures for heart failure, outlines a plan for patients with heart failure that includes anticoagulation for patients with atrial fibrillation. Care guidelines created by The Joint Commission, the ACC, the AHA, and other professional organizations have created a template to guide the patient’s inpatient stay and help nurses formulate a discharge plan.¹¹

Nurses should understand how the pathophysiology of heart failure affects patient care management decisions, applying evidence-based medicine to clinical practice, summarizing for the patient and care providers the heart failure management requirements upon discharge, and ensuring that Joint Commission heart failure core measures are part of discharge planning. The nurse must document this in the medical record, ensuring that critical aspects of heart failure management are part of the plan of care. The bedside nurse can institute these measures and refer complex patient management cases to specialized heart failure clinics and chronic disease case managers for long-term follow-up and support.^12-14

Nursing collaboration — along with an onsite accreditation manager or a program coordinator for the heart failure clinical team — may be one way to help hospital units to improve their adherence to core measures. Strategies to consider include staff education on heart failure guidelines and Joint Commission core measures as well as continuous readiness action plans with core measure reminders. Clinical pathways, preprinted orders, and preprinted discharge forms also make it easier for nurses to incorporate these core measures into daily practice.^12-14

‘Mock’ tracers

Another strategy involves “mock” tracers. During its unannounced survey team visits to hospitals, The Joint Commission traces a real patient from department to department to evaluate care delivery. For example, the hospital journey for a heart failure patient may begin in the ED, followed by a visit to radiology for a chest X-ray. The patient then may require phlebotomy assistance for labs and contact with pharmacy for critical medication. Finally, the patient may be transferred to an inpatient unit.

A trial run with a mock heart failure patient will highlight the effectiveness of improvement efforts involving the core heart failure measures. Consider using a robotic patient that can be programmed to mimic signs of heart failure, as is done in critical care education settings, so that care initiatives can be timed and recorded. Include all involved personnel and healthcare professionals in the mock tracer debriefing so that their feedback can be incorporated into the practice setting.^12-14

One expert recommends the following when planning a mock tracer process: 1) Select high-priority areas and clinical problems for review; 2) analyze active patient records that reflect the dynamic aspect of care delivery; 3) plan the tracer activity so that it includes all patient care areas and clinical service groups affected; 4) involve someone knowledgeable about Joint Commission standards; and 5) analyze the mock tracer activities to determine trends and select priorities for change. Although mock tracers are not a Joint Commission requirement, they may uncover areas of nonadherence and generate creative approaches to improve care delivery methods.¹⁴

Fitting in teaching

As lengths of stay shorten, the staff nurse must find creative ways to ensure that heart failure patients understand the prescriptive care at discharge. Nurses can advocate for a nursing role on committees that create new discharge documents and designate changes in healthcare delivery systems. They can promote the use of computerized charting that incorporates treatment guidelines, Joint Commission mandates, and algorithms for care. Nurses also can find ways to keep heart failure patient education ongoing through the patient’s stay; on the day of discharge, staff may face many other demands.^12-14

Guide inpatients and families to be active in heart failure management to the extent possible. For example, encourage patients to weigh themselves on a unit scale and enlist a dietitian to teach them to record the sodium and fluid intake of their inpatient meals. Provide written information on inpatient medications so that they can see the intended treatment effect and begin to raise questions about factors that may affect adherence after discharge.^12-14

Consider new ways to educate fellow staff nurses on heart failure care and associated Joint Commission mandates. Investigate resources listed in the sidebar. Seek out source documents, such as the Specification Manual for National Hospital Quality Measures, and visit the Joint Commission website periodically for updates to the “Heart Failure Core Measure Set.” Preparations for Joint Commission visits can be ongoing, in tune with the continuous improvement pattern of healthcare operations that the commission favors. This approach lends value to the accreditation process — and facilities that receive high Joint Commission ratings may gain respect from the consumers and communities they serve.^12-14

In summary, understanding heart failure presentation and evidence-based guidelines for care management helps nurses prepare patients for discharge. A thorough knowledge of The Joint Commission core measures for heart failure and their implementation as a part of nursing practice are keys to a successful Joint Commission survey.