The Ins & Outs of Hospitalization for Heart Failure (Part Three)
Third of a four-part series on heart failure
The term “heart failure” often elicits a fearful response. It sounds disastrous, like a heart that stops beating all of a sudden. But that is called sudden cardiac arrest. Heart failure (HF) is the name given to a condition where an abnormal heart muscle is unable to keep up with its workload of pumping blood, oxygen and nutrients to the body. It is a chronic condition, but it can be managed and in today’s world, managed well.
In our first two installments of this four-part series on HF we discussed the two forms of this condition — Heart Failure with Reduced Ejection Fraction (HFrEF, referred to as “hefref”) and Heart Failure with Preserved Ejection Fraction (HFpEF, “hef-pef”). In this third installment we will discuss hospitalization, which HF treatment may require.
It is safe to say that none of us wants to go into the hospital. However, when symptoms of HF worsen and cannot be managed at home, patients may need to be hospitalized, sometimes repeatedly.
Many times patients delay calling their physician about symptoms for fear that they will end up in the hospital. While the emotions of this are understandable, it is not an effective response because the symptoms can get much worse, which could require a longer hospital stay. (See “Self-Check Plan” infographic (Spanish version available here) to help you monitor your HF and take appropriate action when needed.)
Dr. Kathleen Grady
“Hospitalization or re-hospitalization is something patients really don’t want,” said Kathleen L. Grady, Ph.D., R.N., M.S., administrative director of the Center for Heart Failure and professor, Departments of Surgery and Medicine, Feinberg School of Medicine at Northwestern University in Chicago. “It happens for a variety of reasons — the HF itself may be worsening or patients may develop worsening symptoms from other conditions, like an infection. It may be challenging to stick to what can often be a complicated medical regimen, such as not taking medications as prescribed, not following a low-sodium diet or not calling the doctor soon enough when symptoms present. Hospitalization, especially if it is frequent, is a time for patients and doctors to identify how the patient can be better supported in managing their HF when they aren’t in the hospital. A discussion regarding next steps is often needed — where do we go from here.”
Typically, when patients are hospitalized for HF, it is not the first time they are hearing about the condition. Understanding why they’ve been hospitalized is important. If patients are there because their condition is worsening, then additional evaluation needs to take place. If there is an issue with the plan of care, then their hospital stay is a good time to identify the challenges, so that care providers and patients can work together to find a better process of care. Are financial challenges keeping them from buying their medication? Do they have proper support at home? Do they understand what a low-sodium diet is? “It’s really important when patients are hospitalized to help them identify HF self-care strategies and potentially reduce frequent rehospitalizations,” Grady said.
Grady points out that early follow up after hospitalization, generally with a phone call from the medical team, helps ensure patients are taking the right medicines at the right dose and frequency. Grady likes for patients to make a follow-up clinic visit shortly after they’ve been discharged to evaluate how they’re doing. That visit should not only include the usual physical exam, but also a follow-up discussion on self-care and if the patient is feeling confident about how they’re managing their HF. “It’s important for HF patients who have been hospitalized to be seen on a regular basis,” Grady added. “That can help keep them out of the hospital. It’s even better when the people helping care for them at home also participate in the discussion.”
Much HF treatment relies on medication, and that can be a challenge all by itself. A crucial part of meeting that challenge is medication reconciliation. That should happen when the patient first comes to the hospital and again before discharge. The first step, upon hospital admission, is to identify the medications the person has been taking as an outpatient. This is typically done by a nurse who talks with the patient and family. “It’s best if that information can be double checked with outpatient medical records, to make sure that a patient is taking everything their providers have prescribed and not more than prescribed,” Grady said.
During hospitalization, there may be medication changes. Medications previously taken at home may be discontinued. A thorough discussion with both the patient and their caregiver about all the medications to be taken and any that were stopped needs to happen at discharge. That discussion should include:
- what each medication is for,
- the correct doses and frequency,
- side effects, and
- very important — making sure they have access to those medications with prescriptions.
“Nurses and pharmacists can be invaluable in doing that medication reconciliation with the patient and the family member,” Grady said.
Follow-up clinic visits should also include medication reconciliation. This is why patients are often asked to bring in all their medicines so that the clinic nurses and doctors can see exactly what the person is taking. “That is critical to ensure that patients are taking the right medicines, only those medicines, and none other,” Grady said. “Of course, it can become really challenging when they have several conditions, such as diabetes, high cholesterol and kidney disease, and are taking 10 or more medications once or twice a day, often prescribed by different doctors. If there are discrepancies in medication dosing, patients are encouraged to talk to the doctor who prescribed the medication. It’s also important for clinicians to talk to one another, to help the patient with taking all of the right medications all of the time.”
Grady urges patients and caregivers to think of discharge as a process that begins on the first day in the hospital. Patients and families need to share any problems they are having with their healthcare team. It’s better to identify the barriers to following their treatment plan while they’re in the hospital, so that the medical team can work with them to find solutions, such as:
- Making sure patients and caregivers understand HF and related conditions they may be managing.
- Teaching them skills (such as how to monitor HF symptoms and how to choose a low-sodium diet).
- Discussing ways to increase support at home (both practical support and emotional support).
- Simplifying the medication regimen when possible.
- Substituting medications when drug side effects occur.
“We really want to promote HF self-care while patients are hospitalized,” Grady said. “We want to ensure that they are knowledgeable about their discharge plan of care and able to implement the plan. Being an active partner in developing the plan of care, while hospitalized, can promote successful self-care at home.”
The Challenge of Self-Care
Patients with HF often have a lot to do to take care of themselves, especially if they have other conditions such as hypertension, diabetes or kidney problems. This means that they may have multiple care plans that they’re trying to follow. “It can really make self-care challenging and difficult,” Grady said. “Following a diet that addresses multiple chronic conditions — low fat, low salt, low sugar, perhaps low potassium — can be very difficult and frustrating from a patient’s perspective, seemingly almost impossible,” Grady said. She indicated that a dietitian should be part of the medical team, and patients should ask for one, if not.
Patients with HF Frequently Have Depression
“Depression can contribute to not managing care well at all,” Grady said. It can definitely affect how well they stick to their medical regimen.
A lack of understanding health information can also lead to inappropriate decisions in regards to self-care. “Many HF patients have limited health knowledge, and that makes it challenging to adhere to the regimen,” Grady said. “Poor health literacy can decrease their confidence in taking care of themselves as well, and it can contribute to poor outcomes like increased mortality.” For example, some patients may not understand the term “sodium” when reading food labels for a low-sodium diet.
Patients should ask their providers about anything they are the least bit unclear about, even asking the same question more than once if needed. It is a good idea to keep a notebook or tablet handy to keep track of questions to ask the healthcare team during the next day’s rounds, as well as to record the physician’s answers.
Quality of Life
Grady points out that HF adversely affects quality of life and the worse the condition, the greater the effect. Shortness of breath, fatigue and depression all impact HF patients. They may be unable to walk across the room or may need to sleep in a semi-reclining position because of fluid retention. “They are often, as it gets worse, unable to work and have frequent re-hospitalizations, which also affects their quality of life,” Grady said. They may be socially isolated, because they just don’t feel good and can’t do the things they usually do with friends.
Family caregivers may be called upon to provide myriad tasks — filling pillboxes, ferrying patients to appointments — as well as providing emotional support. What is true for patients is true for caregivers: the worse the HF, the greater the caregiver’s burden, which may affect their quality of life. It can be especially difficult if the caregiver is the spouse and of a similar age, because they may have their own health problems. “It can be a real challenge for them to be the caregiver,” Grady said. “But despite the burden, some of them find there are positives that bring them closer together as they deal with HF. It may bring family to visit more often. Sometimes estranged families renew their relationships.”
While there are clearly positives, it’s a condition that does, eventually, have a terminal course. Some patients with advanced HF may be candidates for surgical interventions, like heart transplantation or mechanical circulatory support. “Patients who undergo these therapies and do well can improve not only their length of life, but also their quality of life,” Grady said.
“The ultimate goal of promoting HF self-care is to reduce the frequency of HF hospitalizations and enhance patient outcomes, including both survival and quality of life,” Grady said.
A Big Heart Problem (Part One)
The Unrelaxing Heart feat. Queen Latifah & Her Mom Rita Owens (Part Two)