Nurses' Role

The nurses' role on the outpatient unit is all-encompassing, just as it is on the inpatient unit. They educate and reinforce the need for patients to weigh themselves to determine fluid retention, to exercise daily and to eat healthy food. But it also includes evaluating their condition by assessing fluid volume with a brain natriuretic peptide, using a noninvasive hemodynamic monitor to measure and monitor the cardiac cycle including cardiac output, stroke volume, systemic vascular resistance, contractility and fluid status, stat laboratory blood work, taking their blood pressure and reviewing their medications.

Another important role, whether for heart failure outpatients or inpatients, is simply to take the time to talk to patients, whether it's related to their treatment or to hear family stories, according to Mary McGinty, RN, a care manager on the inpatient unit along with Dennis Hunter, RN. "Time and again we see how beneficial it is to sit down and talk, to hear their life stories, about their kids and grandkids. It makes patients feel better and become more motivated to follow directions. In return, it is rewarding to us by helping them to feel more comfortable."

"We try to really get to know patients on a personal level," Townsend said. The entire heart failure team, which includes representatives from pharmacy, cardiac rehabilitation, case management and a massage therapist, "shares a vision to narrow the gaps in care that historically have plagued this population.

"We work with them in whatever interests them to keep active," she continued. One example: investing in a Wii computer game so patients can continue to enjoy bowling, albeit with the help of a computer. Sometimes outpatients simply want to ask questions about what they can and cannot do. They may need help faxing a medical form or guidance in obtaining medications. Digital scales are provided to patients who don't have one at home to facilitate compliance on daily weights.

Many of the outpatient heart failure unit's patients are referred from the inpatient unit, where nurses evaluate their mobility and ability to care for themselves prior to discharge. Unlike many diseases, there is no cure for heart failure; once someone is diagnosed with it, medications are needed for the rest of his life, and exacerbation and frequent hospitalizations to stabilize symptoms are the norm.

Patients typically are considered candidates for outpatient services when they have reached stage 3 or 4, Townsend said, and the outpatient unit sees them every couple of weeks or even once a week if they are having trouble managing symptoms. "A lot of patients need constant follow-up, someone attuned to their specific needs," emphasized Rosemary Serock, BSN, BA, RN, a cardiac rehab nurse on the inpatient unit. "The staff has a good picture of how to fine-tune their care."

Inpatient Care Stresses Mobilization

Typically there are 10-15 patients in the inpatient heart failure unit, where stabilization and education are the staff's primary goals. Admission generally means patients have exhibited signs of heart failure emergently, Serock explained. "We see patients in all four stages of the disease, from no symptoms, to mild symptoms with ordinary activities, to more severe symptoms."

Serock said the emphasis on the inpatient unit is on getting heart failure patients out of bed and ambulating to build up energy levels. "Research proves there is a gap in the mobility of patients when they come to the hospital, because getting up and moving is problematic for them. The goal of the team is early ambulation to prevent complications and to maintain or improve their baseline functional capacity.

"We also have to constantly educate, repeat and reinforce what they must do on their own. You can never have too much of that."

Filling in the Blanks

Some 39 percent of patients seen by the Lourdes heart failure team are uninsured, according to hospital statistics. This means if it were not for the center's services, there would be a tendency for these patients to "get lost to follow-up because of a lack of resources," Serock commented.

The center cares for patients regardless of insurance status, she stressed. "We identify their status when they come in; case management and social services coordinate services so they can obtain medications and other necessary medical supplies. Of course, we encourage them to follow up at the outpatient center."

The center's staff can see the benefits of the total package they provide to heart failure patients. "We focus on all the positives," Serock said. "Every piece of education we emphasize is to improve quality of life. If they follow only one thing it is worth it."

Bette Mooney is a freelance writer and retired editor at ADVANCE.