Ongoing Monitoring and Management
The management of acute breathlessness or cardiopulmonary instability is generally carried out simultaneously with diagnosis. Once the diagnosis of acute heart failure is made, diuretics are administered to relieve dyspnoea. Ideally the dose should be the lowest needed to reduce fluid congestion and so balance the positive action with any potential negative effect on renal function. Close monitoring of renal function, fluid balance and urine output are therefore needed. There is often a tendency to assume urinary catheterisation for the close monitoring of urine output. However, urinary tract infection attributed to urinary catheterisation is the most frequent cause of hospitalacquired infection and in acute hospitals may account for as many as 20 % of all hospital-acquired infections. Risk increases the longer a catheter is in situ, with a daily risk estimated as between 3–7 %.6 This risk is likely to be increased further in the older adult with more health problems. The consequences of such an infection are likely to vary, increasing the risk of a prolonged hospital stay and the development of in-hospital confusion, particularly in older adults. Alongside nursing actions to prevent infection, good practice also includes limiting the use of urinary catheters and, when they are necessary, removal as soon as possible. National and international guidelines suggest best practice in their use.7,8 In the context of acute heart failure this guidance can be interpreted to suggest urinary catheterisation should be restricted to those patients with cardiopulmonary instability and low cardiac output, when hourly urine output monitoring is needed.
The ongoing monitoring of response to treatment and cardiopulmonary status also necessitates close monitoring of key haemodynamic parameters. In the immediate period of stabilisation, overly aggressive management with diuretics and vasodilators may lead to hypotension. Equally, patients may be undertreated or their underlying condition may deteriorate. Early warning scores allocate and weight points to vital signs outside pre-agreed ranges. These points are then summed to provide a single composite score. An increase in score will identify those patients who will benefit from escalation of monitoring or treatment. For example, they may benefit from an increased frequency of observationor ugent medical review. Escalation of treatment and alterations in management are then made in line with the ‘score’. To provide standardisation and limit misunderstanding the UK has adopted the National Early Warning Score (NEWS)9 (see Figure 1) for use in routine recording of clinical data, replacing traditional observation charts. Such tools have been reported to improve the ability of ward staff (both nursing and medical) to identify and respond to indicators of clinical change.10
Close monitoring requires a care environment where nurses have the time and expertise to identify and respond appropriately to changes in physiological data. The association between the competence of nurses and quality of care has long been recognised and more recently the association between nurse staffing, nurse expertise and patient outcome has been confirmed. A study of more than 400,000 patients in 300 acute hospitals in nine European countries reported an association between an increase in the number of nurses and the risk of death. An increase in a nurse’s workload by one patient increased the likelihood of a patient dying by 7 % (OR 1.068, 95 % CI [1.031–1.106]). Conversely, the risk of death was reduced where patients were cared for by academically prepared nurses; every 10 % increase in the number of bachelor-degree nurses on the ward decreased the likelihood of death by 7 % (OR 0.929, 95% CI [0.886–0.973]).11 The authors concluded that patients in hospitals in which 60 % of nurses held bachelor degrees and in which the nurse-to-patient ratio was 1:6 would have an almost 30 % reduced risk of death than patients in hospitals in which only 30 % of nurses had bachelor degrees and each cared for eight patients.11 Within the context of heart failure the UK National Heart Failure audit revealed that in-hospital mortality is lower when patient care is managed in specialist cardiology wards rather than general medical wards (7.8 % versus 13.2 %).5 Taken together these papers suggest that outcome is improved when in-patient care is provided by a specialised team and by ward nurses familiar with the management of heart failure. Countries will need to decide locally how to interpret and implement these findings but they point to an association between the quality of nursing care and patient outcome.
It is not always possible for every patient to receive in-patient care on a specialist cardiology ward and some will be best cared for on general medical or care-of-the-elderly wards where nursing staff have specific expertise in managing the care needs of the frail, older adult. The heart failure management of the older adult is complicated by concomitant comorbid conditions, altered pharmacokinetics, frailty and cognitive impairment. Consequently their hospital length of stay is likely to be longer and also influenced by the availability of post-discharge social support. The UK National Audit data reports an increased length of stay (LOS) in heart failure patients not cared for on cardiology wards and this relates to the majority of those patients aged above 74 years (mean LOS 12.7 days (cardiology ward) versus 13.1 days (general medical) and 14.7 days (other ward areas)).5 The in-patient hospital stay allows review of all medication, as well as combinations that may increase the risk of side effects. The in-patient admission also provides time for the safe introduction of new heart failure medication and this is likely to be slower in the older patient. When accompanied by close monitoring of physiological variables and assessment of the patient’s ability to manage potential effects, such as lower systolic blood pressure or increased diuresis, the in-patient stay can increase the safe prescription of medication, as well as positively influence patient compliance. For example, nurses can remind patients to stand up slowly to reduce their risk of dizziness and falls, teach them to modify the timing of diuretics to enable activities outside the home and facilitate the supply of continence aids when necessary. Where in-patient care is not provided on a cardiology ward this can be facilitated by regular outreach by the heart failure team and the heart failure specialist nurse has a central role in this, providing advice, education and liaison between the health-care teams directly involved in providing care and the heart failure specialist team.
Regardless of the place care is delivered, ideally patients with heart failure should be identified and followed up during their hospital stay by a specialist heart failure team. Using medical admission records the heart failure specialist nurse can identify patients with suspected heart failure, act as a point of contact for advice and ensure appropriate discharge planning and follow up. Once stabilised patients should be started or restarted on evidence medicines. Various models for such outreach exist but the exact model will depend on the local organisation of care.12