- Email: [email protected]
The Challenge of Preventing Contrast Induced Nephropathy in the Cardiac Patient
S408
consider mechanisms to incorporate the assessment of patients’ likelihood to benefit as integral to the multidisciplinary THV eligibility assessment and case selection processes of care. We will highlight the pivotal role and contributions of cardiovascular nurses in the conduct of functional status assessment. Lastly, we will discuss approaches to including measures of utility and futility in program evaluation, including international consensus recommendations for outcome measurement, and local, provincial, and national models to support program evaluation. The rapid pace of innovations in THV techniques offers new treatment options for patients at excessive risk for conventional surgery, and future opportunities for a paradigm shift in the management of structural heart disease. Ensuring the utility of THV procedures, and promoting the role of nursing in patient assessment and advocacy, are essential to the success of THV program development. N050 DIURETIC DIVERSION; INTRAVENOUS DIURETIC DELIVERY IN A CLINIC SETTING AVERTS HOSPITALIZATIONS FOR HEART FAILURE PATIENTS J Harrison, C Clark, L Blair, J Allen, D Pahal Southlake Regional Health Centre, Newmarket, ON
Current health care constraints and the recent focus on the costs associated with heart failure patient admissions, it is imperative that heart function clinics develop strategies which avert an admission for the decompensated heart failure patient. Intravenous access and intravenous diuretic delivery within a clinic setting is an optimal initiative to intervene in patients showing signs of fluid volume overload where oral diuretics are failing. The ability to assess and safely and effectively manage these heart failure patients who would normally require hospital admission is changing the paradigm of heart failure management in Canada. Assessment and medical optimization of significant exacerbated heart failure without a hospital admission minimizes the cost to the health care system and impacts hospital budget burden, however, it is essential that an infrastructure be developed to support this type of care. This presentation will focus on the successful development and implementation of a fully integrated intravenous diuretic management program in a regional centre heart function clinic. Discussed will be the critical elements of the clinic infrastructure, policy development as well as the health care team responsibilities and the patient outcomes related to emergency room and hospital diversions. N051 CHRONIC TOTAL OCCLUSION PERCUTANEOUS CORONARY INTERVENTION: STENTING THE PROVERBIAL MOUNTAIN D Poettcker1, K Coupland2, L Avery1, M Vo2 1
WRHA Cardiac Sciences, Winnipeg, MB, 2 St. Boniface Hospital, Winnipeg, MB
Canadian Journal of Cardiology Volume 29 2013
A coronary chronic total occlusion (CTO) is defined as a complete blockage of a coronary artery which has been present for greater than 3 months and typically may have collateralization of the distal vessel. The purpose of this presentation is to describe the experience and the treatment of coronary chronic total occlusion (CTO) and patient outcomes at a local tertiary cardiac centre. According to the 2012 Canadian Registry the prevalence of CTO lesions is 18%. Traditionally, the approach to treatment has been medical management or coronary bypass surgery with less than a 10% attempt rate for percutaneous coronary intervention (PCI). Recently, PCI with hybrid techniques has become an alternative treatment strategy but requires experienced operators and specialized equipment. In August, 2012, the CTO PCI program was established at our local centre. During the first six months a total of 38 procedures were performed. Preliminary pre and post patient data revealed that CTO PCI is a viable treatment option with a high procedural success rate of over 90% and a low complication rate (none of which resulted in death). Currently clinical outcome data is lacking and our compiled local data will contribute to a larger repertoire of clinical outcomes for this patient cohort across Canada. Cardiac nurses play an important role in the entire care continuum of the CTO PCI population. This includes the assessment and follow-up of patients and the contribution of their clinical knowledge and expertise in the overall planning and evaluation of the CTO PCI program.
N052 THE CHALLENGE OF PREVENTING CONTRAST INDUCED NEPHROPATHY IN THE CARDIAC PATIENT K Pyne, C MacKenzie Ottawa Hospital Heart Institute, Ottawa, ON
Recent changes in the care of patients undergoing angiographies and percutaneous interventions have shown that more interventionalists are prescribing pre and post intravenous hydration therapy. Hydration therapy minimizes the effects of contrast induced nephropathy. [CIN] This proves to be a challenge as CIN is the third leading cause of hospital acquired renal failure. The impact of CIN is continuing to rise in hospitals. Literature has shown that CIN is associated with increased hospital admissions, longer length of stay and increased costs. Patients requiring angiographies or imaging often have some type of cardiac disease. They are frequently elderly, with many comorbidities such as diabetes and chronic kidney disease. Contrast and intravenous volume are important contributors to their risk factors with those that have Acute Coronary Syndrome. Many treatments have been attempted in preventing contrast induced acute kidney injury, for example using mucomyst, sodium bicarbonate, diaysis and of course intravenous hydration. Intravenous therapy appears to be less invasive and cost effective, the primary standard in managing contrast based kidney injury.
CCCN Abstracts
This presentation will reflect on the history of renal protection, the pros and cons of different methods of preventing CIN and the state of the science at present. The expert clinical experience of an active cardiac unit that averages twenty-eight angiograms a day will demonstrate current practices and the challenges of the lack of evidence to support the practice. N053 MIND THE GAP: HEART FAILURE AND END-OF-LIFE CARE PLANNING CHALLENGES L Brubacher, M Linghorne, H Pappas, N Jamal, Q Xu, N Thomson, J Downar University Health Network: Toronto General Hospital, Toronto, ON
Heart failure is a serious condition which is recognized to be equivalent to malignant disease in terms of mortality and symptom burden. As a result, there is growing recognition for the need to improve end-of-life care planning for patients with heart failure. The uncertainties in prognosis and recent technological advances have also led to increased complexity of care and decision-making at the end of life. Communication and shared decision making is the cornerstone to providing end-of-life care planning in an effort to promote quality patient-centered care. This presentation will share the experience of a group of Nurse Practitioners (NPs) working on an inpatient cardiology unit at a quaternary care center in Toronto, and their efforts to change their practice in order to improve the quality of their patients’ end-of-life experience. A brief overview of the challenges to endof-life communication in heart failure as outlined in the current literature will be reviewed. Recognizing their own need for improved communication skills in a practice environment where there is increased complexity of care and decision-making at the end of life, lead them to attend a formal communication workshop. A brief description of the workshop lead by a palliative care physician will be described. The results of a pre and post workshop questionnaire will demonstrate the positive impact the workshop had on improving their comfort in discussing advance care planning with patients. Strengthening communication is the beginning to changing NP practice for end-of-life care planning in an effort to promote quality patient-centered care. N054 USING IVR TECHNOLOGY FOR IMPROVED SELF-CARE IN HEART FAILURE PATIENTS e TARGETED INTERVENTIONS FOR MAXIMUM BENEFITS D Smaglinski, C Struthers University of Ottawa Heart Institute, Ottawa, ON
Heart failure (HF) is an increasingly prevalent chronic condition. Improving self-care is known to reduce hospital readmission rates. Supporting patients with self-care and timely intervention is important during the transition from hospital to home. The purpose of this study is to evaluate the use of an Interactive Voice Response system on transitional care, selfcare, best practice guideline medications and readmissions.
S409
As part of a prospective descriptive pilot study all HF patients discharged from a Canadian quaternary center who met the inclusion criteria were called by IVR. Calls occurred on the second day post-discharge, then bi-weekly for 3 months. During calls, patients accessed verbal and written self-care information of their choice, while responding to questions that identified a need for further assessment or intervention. Primary outcomes include self-care measured by the Self-Care in Heart Failure Index, medication compliance, readmission rates and patient satisfaction. Secondary outcomes include call disposition (completed, call-back, no contact), the number of assessments and requests for self-care information. As of January 15th, 2013, 8 eligible patients were recruited to participate in the study (1 female; mean age 65 years). Clinical information includes: 6 systolic HF (mean EF 22 %), 2 diastolic HF; 7 NYHA III, 1 NYHA IV. Preliminary call results reveal 5 complete calls, 5 call-backs including 1 emergency visit and 1 stopped medication, and 3 requests for mailed information. This presentation will provide the results of the 6 month pilot, implications for nursing practice and research as well as limitations in using IVR. N055 CARDIOVASCULAR CARE POVERTY: WHERE DO INDIVIDUALS WITH NON-OCCLUSIVE CARDIAC DISEASE GO? K Throndson1, L Avery2, T Duhamel3, K Coupland2, C Kuttnig3, T Nguyen2, F Hussain2, J Zalnasky4, A Mamchuk4 1 Health Sciences Centre, Winnipeg, MB, 2 WRHA Cardiac Sciences Program, Winnipeg, MB, 3 St. Boniface Hospital Research Centre, Winnipeg, MB, 4 Heart and Stroke Foundation, Winnipeg, MB
The purpose of this presentation is to critically appraise and identify knowledge gaps in the literature describing secondary prevention strategies for preventing the progression of coronary artery disease (CAD) in individuals with non-occlusive CAD. A few local initiatives to help address this gap will be discussed. Cardiovascular disease remains one of the leading causes of death and disability in Canada. Guidelines indicate that individual risk factor reduction is integral to decreasing cardiovascular risk. Despite the benefits of risk factor modification in halting the progression of CAD, there remains suboptimal use of prevention strategies in all cardiac populations. Although tertiary care prevention has been proven to reduce morbidity and mortality in patients with occlusive CAD, research evidence on the benefits of tertiary prevention for individuals with non-occlusive disease is lacking. A one month audit of elective coronary angiography patients revealed that 34% of patients had non-occlusive CAD (lesions less than 70%). Currently, few patients with non-occlusive CAD are referred to structured exercise therapy and risk factor reduction programs. Limited research evidence and debate within the professional community contribute to a lack of direction around the most appropriate prevention approach for this at risk cardiac population. Recognizing the financial constraints in healthcare, appropriate resource allocation for prevention strategies needs to be
consider mechanisms to incorporate the assessment of patients’ likelihood to benefit as integral to the multidisciplinary THV eligibility assessment and case selection processes of care. We will highlight the pivotal role and contributions of cardiovascular nurses in the conduct of functional status assessment. Lastly, we will discuss approaches to including measures of utility and futility in program evaluation, including international consensus recommendations for outcome measurement, and local, provincial, and national models to support program evaluation. The rapid pace of innovations in THV techniques offers new treatment options for patients at excessive risk for conventional surgery, and future opportunities for a paradigm shift in the management of structural heart disease. Ensuring the utility of THV procedures, and promoting the role of nursing in patient assessment and advocacy, are essential to the success of THV program development. N050 DIURETIC DIVERSION; INTRAVENOUS DIURETIC DELIVERY IN A CLINIC SETTING AVERTS HOSPITALIZATIONS FOR HEART FAILURE PATIENTS J Harrison, C Clark, L Blair, J Allen, D Pahal Southlake Regional Health Centre, Newmarket, ON
Current health care constraints and the recent focus on the costs associated with heart failure patient admissions, it is imperative that heart function clinics develop strategies which avert an admission for the decompensated heart failure patient. Intravenous access and intravenous diuretic delivery within a clinic setting is an optimal initiative to intervene in patients showing signs of fluid volume overload where oral diuretics are failing. The ability to assess and safely and effectively manage these heart failure patients who would normally require hospital admission is changing the paradigm of heart failure management in Canada. Assessment and medical optimization of significant exacerbated heart failure without a hospital admission minimizes the cost to the health care system and impacts hospital budget burden, however, it is essential that an infrastructure be developed to support this type of care. This presentation will focus on the successful development and implementation of a fully integrated intravenous diuretic management program in a regional centre heart function clinic. Discussed will be the critical elements of the clinic infrastructure, policy development as well as the health care team responsibilities and the patient outcomes related to emergency room and hospital diversions. N051 CHRONIC TOTAL OCCLUSION PERCUTANEOUS CORONARY INTERVENTION: STENTING THE PROVERBIAL MOUNTAIN D Poettcker1, K Coupland2, L Avery1, M Vo2 1
WRHA Cardiac Sciences, Winnipeg, MB, 2 St. Boniface Hospital, Winnipeg, MB
Canadian Journal of Cardiology Volume 29 2013
A coronary chronic total occlusion (CTO) is defined as a complete blockage of a coronary artery which has been present for greater than 3 months and typically may have collateralization of the distal vessel. The purpose of this presentation is to describe the experience and the treatment of coronary chronic total occlusion (CTO) and patient outcomes at a local tertiary cardiac centre. According to the 2012 Canadian Registry the prevalence of CTO lesions is 18%. Traditionally, the approach to treatment has been medical management or coronary bypass surgery with less than a 10% attempt rate for percutaneous coronary intervention (PCI). Recently, PCI with hybrid techniques has become an alternative treatment strategy but requires experienced operators and specialized equipment. In August, 2012, the CTO PCI program was established at our local centre. During the first six months a total of 38 procedures were performed. Preliminary pre and post patient data revealed that CTO PCI is a viable treatment option with a high procedural success rate of over 90% and a low complication rate (none of which resulted in death). Currently clinical outcome data is lacking and our compiled local data will contribute to a larger repertoire of clinical outcomes for this patient cohort across Canada. Cardiac nurses play an important role in the entire care continuum of the CTO PCI population. This includes the assessment and follow-up of patients and the contribution of their clinical knowledge and expertise in the overall planning and evaluation of the CTO PCI program.
N052 THE CHALLENGE OF PREVENTING CONTRAST INDUCED NEPHROPATHY IN THE CARDIAC PATIENT K Pyne, C MacKenzie Ottawa Hospital Heart Institute, Ottawa, ON
Recent changes in the care of patients undergoing angiographies and percutaneous interventions have shown that more interventionalists are prescribing pre and post intravenous hydration therapy. Hydration therapy minimizes the effects of contrast induced nephropathy. [CIN] This proves to be a challenge as CIN is the third leading cause of hospital acquired renal failure. The impact of CIN is continuing to rise in hospitals. Literature has shown that CIN is associated with increased hospital admissions, longer length of stay and increased costs. Patients requiring angiographies or imaging often have some type of cardiac disease. They are frequently elderly, with many comorbidities such as diabetes and chronic kidney disease. Contrast and intravenous volume are important contributors to their risk factors with those that have Acute Coronary Syndrome. Many treatments have been attempted in preventing contrast induced acute kidney injury, for example using mucomyst, sodium bicarbonate, diaysis and of course intravenous hydration. Intravenous therapy appears to be less invasive and cost effective, the primary standard in managing contrast based kidney injury.
CCCN Abstracts
This presentation will reflect on the history of renal protection, the pros and cons of different methods of preventing CIN and the state of the science at present. The expert clinical experience of an active cardiac unit that averages twenty-eight angiograms a day will demonstrate current practices and the challenges of the lack of evidence to support the practice. N053 MIND THE GAP: HEART FAILURE AND END-OF-LIFE CARE PLANNING CHALLENGES L Brubacher, M Linghorne, H Pappas, N Jamal, Q Xu, N Thomson, J Downar University Health Network: Toronto General Hospital, Toronto, ON
Heart failure is a serious condition which is recognized to be equivalent to malignant disease in terms of mortality and symptom burden. As a result, there is growing recognition for the need to improve end-of-life care planning for patients with heart failure. The uncertainties in prognosis and recent technological advances have also led to increased complexity of care and decision-making at the end of life. Communication and shared decision making is the cornerstone to providing end-of-life care planning in an effort to promote quality patient-centered care. This presentation will share the experience of a group of Nurse Practitioners (NPs) working on an inpatient cardiology unit at a quaternary care center in Toronto, and their efforts to change their practice in order to improve the quality of their patients’ end-of-life experience. A brief overview of the challenges to endof-life communication in heart failure as outlined in the current literature will be reviewed. Recognizing their own need for improved communication skills in a practice environment where there is increased complexity of care and decision-making at the end of life, lead them to attend a formal communication workshop. A brief description of the workshop lead by a palliative care physician will be described. The results of a pre and post workshop questionnaire will demonstrate the positive impact the workshop had on improving their comfort in discussing advance care planning with patients. Strengthening communication is the beginning to changing NP practice for end-of-life care planning in an effort to promote quality patient-centered care. N054 USING IVR TECHNOLOGY FOR IMPROVED SELF-CARE IN HEART FAILURE PATIENTS e TARGETED INTERVENTIONS FOR MAXIMUM BENEFITS D Smaglinski, C Struthers University of Ottawa Heart Institute, Ottawa, ON
Heart failure (HF) is an increasingly prevalent chronic condition. Improving self-care is known to reduce hospital readmission rates. Supporting patients with self-care and timely intervention is important during the transition from hospital to home. The purpose of this study is to evaluate the use of an Interactive Voice Response system on transitional care, selfcare, best practice guideline medications and readmissions.
S409
As part of a prospective descriptive pilot study all HF patients discharged from a Canadian quaternary center who met the inclusion criteria were called by IVR. Calls occurred on the second day post-discharge, then bi-weekly for 3 months. During calls, patients accessed verbal and written self-care information of their choice, while responding to questions that identified a need for further assessment or intervention. Primary outcomes include self-care measured by the Self-Care in Heart Failure Index, medication compliance, readmission rates and patient satisfaction. Secondary outcomes include call disposition (completed, call-back, no contact), the number of assessments and requests for self-care information. As of January 15th, 2013, 8 eligible patients were recruited to participate in the study (1 female; mean age 65 years). Clinical information includes: 6 systolic HF (mean EF 22 %), 2 diastolic HF; 7 NYHA III, 1 NYHA IV. Preliminary call results reveal 5 complete calls, 5 call-backs including 1 emergency visit and 1 stopped medication, and 3 requests for mailed information. This presentation will provide the results of the 6 month pilot, implications for nursing practice and research as well as limitations in using IVR. N055 CARDIOVASCULAR CARE POVERTY: WHERE DO INDIVIDUALS WITH NON-OCCLUSIVE CARDIAC DISEASE GO? K Throndson1, L Avery2, T Duhamel3, K Coupland2, C Kuttnig3, T Nguyen2, F Hussain2, J Zalnasky4, A Mamchuk4 1 Health Sciences Centre, Winnipeg, MB, 2 WRHA Cardiac Sciences Program, Winnipeg, MB, 3 St. Boniface Hospital Research Centre, Winnipeg, MB, 4 Heart and Stroke Foundation, Winnipeg, MB
The purpose of this presentation is to critically appraise and identify knowledge gaps in the literature describing secondary prevention strategies for preventing the progression of coronary artery disease (CAD) in individuals with non-occlusive CAD. A few local initiatives to help address this gap will be discussed. Cardiovascular disease remains one of the leading causes of death and disability in Canada. Guidelines indicate that individual risk factor reduction is integral to decreasing cardiovascular risk. Despite the benefits of risk factor modification in halting the progression of CAD, there remains suboptimal use of prevention strategies in all cardiac populations. Although tertiary care prevention has been proven to reduce morbidity and mortality in patients with occlusive CAD, research evidence on the benefits of tertiary prevention for individuals with non-occlusive disease is lacking. A one month audit of elective coronary angiography patients revealed that 34% of patients had non-occlusive CAD (lesions less than 70%). Currently, few patients with non-occlusive CAD are referred to structured exercise therapy and risk factor reduction programs. Limited research evidence and debate within the professional community contribute to a lack of direction around the most appropriate prevention approach for this at risk cardiac population. Recognizing the financial constraints in healthcare, appropriate resource allocation for prevention strategies needs to be