Immediate Assessment and Triage

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Immediate Assessment and Triage

From a patient perspective, the acute heart failure journey generally starts with increasing shortness of breath, sometimes accompanied by non-specific signs and symptoms of oedema, fatigue, loss of appetite and changes in weight. Patients seek professional help when their own self-care resources fail or through the encouragement of family or friends. For some, the onset of symptoms is rapid.4 Either way, patients generally have worsening shortness of breath when they present to a hospital emergency department. The UK National Heart Failure Audit provides a detailed picture of the patient admitted to hospital. It reports that almost 80 % of those admitted to hospital with acute or decompensated heart failure present with shortness of breath on at least moderate exercise during their first hospital admission: New Image title York Heart Association (NYHA) III 44 %, NYHA IV 35 %.

At subsequent hospitalisations, the proportion of patients presenting with severe shortness of breath increases modestly: NYHA III 44 %, NYHA IV,40 %.5 On arrival in the emergency department, prompt recognition, management and transfer to an appropriate environment for care are necessary to alleviate both the physical and emotional symptoms of breathlessness and optimise outcome. Unlike the focus on triage of the patient presenting with acute-onset chest pain, emergency departments do not generally have an acute heart failure triage nurse. Therefore the initial patient triage is frequently undertaken by a nurse practitioner who elicits the patient history, assesses the severity of the clinical status and refers to the relevant team. In this way, such nurses play a key role within the multi-professional team by helping to distinguish the cause of breathlessness and initiating prompt symptom relieving therapy.

Key issues in the nurse’s initial clinical assessment of suspected acute heart failure are summarised in Table 2 and adapted from the most recent recommendations on management.3 Nurse practitioners generally have an ‘expanded’ skill set that enables them to also perform clinical examination to identify signs of congestion and refer for chest X-ray. Identifying clinical stability is an important first step in triage and enables the prompt transfer of the patient to the appropriate level of care for safe and effective therapy. This is largely influenced by the local organisation of services and skill sets of ward nurses. However, a patient at high risk of clinical deterioration or one requiring invasive cardiopulmonary support should ideally be transferred to the emergency resuscitation area, or an intensive or coronary care unit offering a lower patient-to-nurse ratio, closer patient monitoring and medical staff more available to support decision making.

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