Marilyn A. Prasun

The effects of a sliding scale diuretic titration protocol in patients with heart failure.

Patients with heart failure (HF) are often instructed to temporarily adjust their diuretic dose. This approach has become routine in some HF management programs; however, no study has specifically examined the effects of a patient-directed flexible diuretic protocol. For the purposes of this study, patients were randomized into a usual care (UC) group (n = 31) or a flexible diuretic titration (DT) group (n = 35). The DT group completed a 6-item diuretic titration protocol once a day, for 3 months. The 6-minute walk distance, plasma B-type natriuretic peptide (NT-BNP), plasma norepinephrine (NE), and quality of life (QOL) were measured at baseline and at 3 months. Hospitalizations, emergency department (ED) visits, and mortality rates were measured at 3 months. Compared to baseline, at 3 months, there was a significant increase in the DT groups 6-minute walk distance (646 ± 60 ft vs 761 ± 61 ft, P = .01) and total QOL score (53 ± 5 vs 38 ± 5, P = .001), whereas these parameters remained unchanged within the UC group. There were significantly less ED visits in the DT group compared with those in the UC group (3% vs 23%, P = .015). No differences were found between the groups in HF-related hospitalizations or mortality. Within both groups, no differences were found between baseline and 3-month NE or NT-BNP plasma values. Patients with heart failure who used a sliding scale diuretic titration protocol had significant improvements in their exercise tolerance and QOL, had fewer ED visits, and had no change in plasma NE or NT-BNP levels.

Being a seasoned nurse in active practice

AIM The purpose of this qualitative study was to discover what rewards and inspires seasoned nurses to continue to practice in acute care after the normal age of nurse retirement, and to identify best practices in retention. BACKGROUND An aging population and an aging nursing workforce are twin issues that bring urgency to this issue. Seasoned nurses have much to contribute to the workforce, but very few studies have examined strategies to retain them. METHODS A grounded theory approach was used in two phases to explore the meaning of being a seasoned nurse. In phase 1, 13 nurses over the age of 62 years were queried about the meaning of being a seasoned nurse actively engaged in acute care nursing. The second phase included 12 nurses in active practice anticipating retirement (aged 55-62 years). Semi-structured interviews were conducted, audiotaped, transcribed and analysed. RESULTS A concept map with four major themes emerged from the data. The themes were identified as (1) pre-existing attitudes and experiences, (2) retention factors, (3) important needs, and (4) unique contributions. CONCLUSIONS Seasoned nurses enjoy, and engage in, nursing and derive benefits from continued practice. Further research is needed to determine the relative importance of the factors identified as important to nurses as they anticipate, and experience, retirement. IMPLICATION FOR NURSE MANAGERS: An understanding of these factors can be used to aid nursing leaders to retain seasoned nurses in practice beyond retirement age.

Flexible Diuretic Titration in Chronic Heart Failure: Where Is the Evidence?

BACKGROUND Several sets of heart failure (HF) consensus/guideline statements support the use of a flexible diuretic dosing regimen for HF outpatient management of fluid overload-related signs and symptoms. However, despite the widespread acceptance of such an approach, the evidence supporting the effectiveness of this approach in improving clinical outcomes is unknown. The primary objective of this manuscript was to summarize and review the evidence supporting the use of a flexible diuretic regimen in the management of outpatient heart failure patients. METHODS AND RESULTS A systematic review was performed, and 9 studies were identified relevant to the question of flexible diuretic titration in the setting of chronic heart failure. Among the 9 studies, 5 were randomized. Three of the randomized trials included flexible diuretic titration as part of a broader multifaceted disease management program, and only 2 were designed to specifically evaluate the sole contribution of flexible diuretic titration. Collectively, data from all of the studies reviewed supported the idea that flexible and individualized diuretic dosing is potentially associated with reduced emergency room visits, reduced rehospitalization, and improved quality of life in HF patients with reduced ejection fraction. CONCLUSIONS To date, only 2 randomized clinical studies were identified that were designed to determine the effects of a flexible diuretic dosing regimen in outpatient HF patients with reduced ejection fraction. Data are lacking in HF patients with preserved ejection fraction. There is a critical need to test this strategy in well designed prospective randomized clinical trials.

HFSA and AAHFN Joint Position Statement: Advocating for a Full Scope of Nursing Practice and Leadership in Heart Failure

The Heart Failure Society of America (HFSA) and theAmerican Association of Heart Failure Nurses (AAHFN)share a common core mission to improve outcomes ofpatients with heart failure. A recent report underscoredthe importance of increasing advocacy efforts to enablenurses to practice to the full extent of their education andtraining and engage in full partnership with physiciansand other health professionals in redesigning health care.

Perceived barriers and facilitators to patients receiving 60 minutes of heart failure education: A survey of AAHFN members

Since its inception, the American Association of Heart Failure Nurses (AAHFN) has assisted heart failure nurses providing appropriate education for their patients. In the most recent strategic plan the Board of Directors specifically targeted ways to enhance and expand patient education resources that our members can use in their clinical practice. This is particularly important as the recognition of 60 min, of inpatient education has been set as a goal by programs that measure outcomes and recognize quality.1,2 The goal of 60 min was supported by research that found a reduction in early readmission in those patients with a total of at least 1 h of inpatient education.3 To provide a baseline assessment as part of our quality improvement efforts, AAHFN devised a survey for membership that would: 1. Assess heart failure (HF) patient provision of 60 min of patient education (60MPE) and preparation for self-care, 2. Identify the barriers to patient education, 3. Assess the difficulty of teaching various topics, and 4. Examine institutional and nurse variables that promote 60MPE. A brief report of the results of the first question was published in a recent AAHFN publication.4 This paper provides a more detailed report of the survey.

Providing best practice in the management of atrial fibrillation in the United States.

Background: Atrial fibrillation (AF) is a prevalent arrhythmia. Patients with AF may report a variety of symptoms and often describe compromised quality of life. Atrial fibrillation increases the risk of stroke, heart failure, and all-cause mortality. Purpose: The purpose of this review article was to provide an overview of AF management based on current guidelines and new data. Conclusions: The 2011 American College of Cardiology Foundation/American Heart Association/Heart Rhythm Society guideline update provides diagnostic and management recommendations for the patient with AF based on the current evidence. Clinical Implications: Nurses are integral to the care of patients with AF. It is essential for nurses to stay apprised of current guidelines and new evidence so that the assessment, management, and education of the AF patients and their families can be optimized.

HFSA and AAHFN joint position statement: Advocating for a full scope of nursing practice and leadership in heart failure

CHRISTOPHER S. LEE, RN, PhD, BARRY H. GREENBERG, MD, ANN S. LARAMEE, APRN, MS, SUSAN E. AMMON, RN, MS, FNP, MARILYN PRASUN, PhD, CCNS-BC, MARIE GALVAO, MSN, ANP-BC, CHFN, LYNN V. DOERING, DNSC, M. EUGENE SHERMAN, MD, LYNNE WARNER STEVENSON, MD, DOUGLAS D. GREGORY, PHD, PAUL A. HEIDENREICH, MD, MS, NAVIN K. KAPUR, MD, JOHN B. O’CONNELL, MD, ANNE L. TAYLOR, MD, JOSEPH A. HILL, MD, PhD, LINDA BAAS, RN, PhD, ACNP, CHFN, ASHLEY GIBBS, RN, MSN, ANP/GNP-BC, CHFN, KISMET RASMUSSON, FNP-BC, CHFN, CONNIE LEWIS, MSN, ACNP-BC, NP-C, CCRN, CHFN, PEGGY KIRKWOOD, RN, MSN, ACNPC, AACC, CHFN, JUANITA REIGLE, RN, MSN, ACNP-BC, CHFN, LISA RATHMAN, MSN, CRNP, CHFN, AND CYNTHIA BITHER, RN, MSN, APN-C, ACNP-C

Treating atrial fibrillation: rhythm control or rate control.

Atrial fibrillation (AF), a rhythm characterized by disorganized depolarization of the atria, is frequently encountered in the clinical setting. This dysrhythmia significantly impacts hemodynamics, exercise tolerance, and quality of life. Many factors contribute to this complex dysrhythmia, ultimately leading to electrical and mechanical remodeling. Rhythm control has been the initial treatment choice for AF. However, until recently, differences in outcomes associated with rhythm control versus rate control for AF were unknown. Data from recent clinical trials suggest that rate control is equivalent to rhythm control in terms of mortality. In the rhythm-control group compared to the rate-control group, there was a tendency for increased hospitalizations and medication reactions (although these differences were not significant). Anticoagulation remains an important component of therapy when treating AF, but continues be to inadequately prescribed. Further, INRs commonly are not maintained in a therapeutic range. Finally, the results of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM), Pharmacological Intervention in Atrial Fibrillation (PIAF), and the Comparison of Rate Control and Rhythm Control in Patients with Recurrent Persistent Atrial Fibrillation (RACE) trials provide guidance in treatment strategies for AF.

Heart Failure Nursing Certification.

Current, active RN license for at least 2 years or equivalent (4160 hours) 1,200 hours within the last 2 years (equates to 29% of time in clinical practice within the previous 2 years) Registered nurse 30 hours of continuing education within the last two (2) years, of which a minimum of 15 hours must be focused on care of patients with heart failure. Current, active RN license for at least 5 years or equivalent (10,400 hours) Registered nurse with a Bachelors of Science in Nursing [BSN] or equivalent bachelors degree þ 2400 hours experience in current role or Masters þ 2080 hours experience in current role Evidence of how nurses are indirectly involved in patients with HF or how nurses complete action(s) in their role that are related to HF 30 hours of heart failure continuing education within the last two (2) years. aging the HF patient population. Within the nursing profession certification recognizes specialized knowledge. According to the American Board of Nursing Specialties (ABNS), specialized certification is defined as “the formal recognition of specialized knowledge, skills, and experience demonstrated by achievement of standards identified by a nursing specialty to promote optimal health outcomes.”2 Certification in HF confirms knowledge about HF nursing care and demonstrates a commitment to quality care.3 Becoming certified as a HF nurse is an important milestone within the profession. Who benefits from Heart Failure Nursing Certification? Everyone benefits when a nurse becomes certified in HF. Patients and their caregivers and families, as well as employers, coworkers and the nurse benefit from certification.

New heart failure treatment and nursing care

The prevalence of heart failure (HF) is projected to increase to greater than 8 million by 2030.1 Improving HF patient outcomes while reducing hospital readmissions has been a focus of health care providers and organizations in recent years. In the past year newHFmonitoring and treatments have been approved. The recent advances include the FDA approval of the CardioMEMs implantable hemodynamic monitoring device which is designed to monitor HF patients at risk of hospitalization. Next, the Centers for Medicare andMedicaid (CMS) approved Cardiac Rehabilitation Phase II for HF patients who have reduced left ventricular ejection fraction (LVEF) and meet the established criteria. Approval of new medications have also occurred with the FDA approval of Corlanor (ivabradine) to reduce the risk of hospitalization for worsening HF and Entresto (TM) [sacubitril/valsartan] formerly known as LCZ696 to reduce risk of cardiovascular death and HF hospitalization. Thus it has been a remarkable year of newly approved treatments that have become available with a focus on improving outcomes of HF patients. Despite the recent new advances in HF, nurses continue to play an important role in assessing, monitoring, and providing patient care while improving outcomes. According to the American Nurses Association, there are approximately 3.4 million registered nurses in the United States many of whom will provide care to HF patients.2 Nurses provide care and manage HF patients across the continuum. Heart failure patients seek and receive care in a wide array of settings with the majority of care outside HF specialty