1. © 2004-2007 Grey Bruce Health Network Congestive Heart Failure Education Workshop (click to go to the desired section) Introduction to Workshop/Instructions Evidence-Based Care Program Congestive Heart Failure Workshop

2. © 2004-2007 Grey Bruce Health Network Introduction This interactive workshop is designed to go along with a workbook. Keep the workbook handy as you go through the workshop to engage in the required activities. This is a web-based workshop, and thus has links throughout each page to enable you to move throughout the workshop. Whenever you see words underlined like this, you can click on that area to go to another section or to find more information on a topic.underlined like this At the bottom of each page are navigational buttons to help you move through the workshop. You can go through as much or as little of the workshop as you like at a time. If you have any questions about how to use this workshop or the individual pathways, feel free to ask your Site Champion. Back to Start of Workshop NextBack

3. © 2004-2007 Grey Bruce Health Network Evidence-Based Care Program These pathways have been developed as a part of the Evidence-Based Care Program, which is Schedule 6 in the agreement of the Grey Bruce Health Network. The intent is to develop regional pathways and other evidence-based tools that flow across all hospitals and community services in Grey and Bruce (including Grey Bruce Health Services, Hanover and District Hospital, South Bruce Grey Health Centre, Grey Bruce Health Unit and the Community Care Access Centre). It is hoped that these pathways will improve: Coordination of care through more communication across professions; Continuity of care, through increased linkages among hospitals and the CCAC; Clinical outcomes, through increased usage of best practices; and Patient satisfaction, through linked expectations and increased patient teaching at our agencies. Back to Start of Workshop NextBack

4. © 2004-2007 Grey Bruce Health Network Congestive Heart Failure Pathway The Congestive Heart Failure (CHF) pathway consists of 7 parts: Clinical Practice Guideline Pre-Printed Orders Patient Pathway Patient Education Booklet Community Resources Sheet Teaching Checklist Clinical Pathway Back to Start of Workshop NextBack

5. © 2004-2007 Grey Bruce Health Network CHF – Clinical Practice Guideline The Clinical Practice Guideline for CHF is “The 2002/3 Canadian Cardiovascular Society Consensus Guideline Update for the Management and Prevention of Heart Failure”, and is found with the electronic pathway materials on the GBHN website. http://www.gbhn.cahttp://www.gbhn.ca It summarizes the evidence used in the development of the pathway. Back to Start of Workshop Back to beginning of section NextBack

6. © 2004-2007 Grey Bruce Health Network CHF – Pre-Printed Orders The orders for this pathway begin in Emergency if the patient arrives through this route, or on the unit if the patient was transferred directly to the unit.orders The inclusion criteria for these orders and the pathway is a patient with a primary admitting diagnosis of Congestive Heart Failure as defined by the New York Heart Association (the definition is listed on the back of the pre-printed orders), more than 18 years old. Back to Start of Workshop Back to beginning of section NextBack

7. © 2004-2007 Grey Bruce Health Network Clinical Pathway This is a Phase-type pathway with two phases. Take a look at it by clicking here. clicking here The pathway is put on the chart when the patient is determined to require admission for Congestive Heart Failure. Phase 1 is approximately 2 days. The patient should remain in this phase, receiving this care, until the patient outcomes have been achieved. If the outcomes have been achieved before the 48 hours, initial to the right of them and flip the pathway to the next page and begin Phase 2. If 48 hours have passed and some outcomes have not been met, the patient will need to stay in Phase 1 until outcomes have been met. Thus, you will need to get an additional blank page of Phase 1, put it in the chart, and keep using Phase 1 until the outcomes have been met. Back to Start of Workshop Back to beginning of section NextBack

8. © 2004-2007 Grey Bruce Health Network Clinical Pathway In the first phase, there are specific goals we are looking for. These are listed in the row of the page called, “Performance Indicators”. There is a tick box to the right of each indicator to input whether they have been met or not met. The rest of the page lists the tasks to be done in the first phase. The same goes for Phase 2, which is also approximately 48 hours. Once the patient achieves the outcomes, move to the Discharge Criteria. Back to Start of Workshop Back to beginning of section NextBack

9. © 2004-2007 Grey Bruce Health Network Clinical Pathway You will notice in Phase 2 in the discharge planning section a referral to cardiac rehab and to the CHF clinic. All patients with CHF are recommended for a referral to both of these clinics. The chest assessment documentation form is used to help you document a chest assessment on a CHF patient. It should be used every time you do a chest assessment on your patient.chest assessment documentation form The Discharge Criteria should be checked daily to see if the criteria have been met. Once all the criteria have been met, then the patient should be ready for discharge.Discharge Criteria Back to Start of Workshop Back to beginning of section NextBack

10. © 2004-2007 Grey Bruce Health Network CHF Patient Pathway The patient pathway has four sections to it:patient pathway Emergency – describes what will happen to the patient when they arrive in emergency. Phase 1 – describes what is done during the first two days of hospitalization, or until the patient achieves the patient outcome indicators for this phase. Phase 2 – describes what is done during the next two days of hospitalization, or until the patient achieves the patient outcome indicators for this phase. Discharge Criteria – describes what the goals are for discharge. This should be given to the patient early in his/her hospital stay and referred to each day to help the patient understand what is happening to him/her. Back to Start of Workshop Back to beginning of section NextBack

11. © 2004-2007 Grey Bruce Health Network Patient Education The education booklet for this pathway is the “Managing Congestive Heart Failure” booklet from the Heart and Stroke Foundation. In addition, the patient should be given the “Community Resources” sheet for reference. Teaching Checklist This is a list of the topics that should be taught or reviewed with the patient before discharge. (see sample)(see sample) It refers directly to the “Managing Congestive Heart Failure” booklet and “Community Resources” sheet. Place the checklist on the chart, and indicate on it as topics are covered so others know what has been taught. Back to Start of Workshop Back to beginning of section NextBack

12. © 2004-2007 Grey Bruce Health Network Cardiac Conditions Community Care Pathway This pathway package is used for those patients that require care from CCAC Nursing provider agencies. See the algorithm for a summary of how this pathway is used.algorithm When the patient is discharged from hospital, the case manager will copy the Variance Record and the Discharge Criteria and send to the provider agency. When the client is admitted for services, the clinical pathway is used for documentation, noting the admission outcomes that have been achieved and the discharge outcomes that were achieved.clinical pathway Back to Start of Workshop Back to beginning of section NextBack

13. © 2004-2007 Grey Bruce Health Network Cardiac Conditions Community Care Pathway The client pathway is given to the patient to help them understand our goals in their treatmentclient pathway The teaching checklist is used to ensure all aspects of teaching are completed before the patient is discharged.teaching checklist When the patient is discharged, a copy of the pathway is sent to the site champion to be forwarded to the Evidence-Based Care Program for evaluation. Back to Start of Workshop Back to beginning of section NextBack

14. © 2004-2007 Grey Bruce Health Network End of CHF Section This is the end of the general information for the CHF pathway. To get further information by trying the pathway on a sample patient, move to the Simulation portion of the CHF workshop.Simulation Test your knowledge by doing the CHF quiz.CHF quiz. Back to Start of Workshop Back to beginning of section NextBack

15. © 2004-2007 Grey Bruce Health Network Simulation Try it! Jane arrives in hospital with congestive heart failure symptoms. She is diagnosed and the attending physician decides to admit her. You check the pathway and Jane fulfills the inclusion criteria for the pathway – find the inclusion criteria on the first page of the pathway. find the inclusion criteria on the first page of the pathway. The pathway should be started in Emergency, as this is where the care begins. If the patient is directly admitted from the physician’s office, the pathway can be started on the unit. The clinical pathway and teaching checklist goes on the chart, and the patient pathway and patient education materials are given to Jane. Take a look at the clinical pathway. On the first page is a master signature sheet. Sign it, and then for the remainder of the pathway you can just initial as tasks are complete (sites with a Master Signature Sheet for your facility will not see this on your pathways).clinical pathway Back to Start of Workshop Back to beginning of section NextBack

16. © 2004-2007 Grey Bruce Health Network Simulation Cont’d There are also some basic instructions on the first page on how to use the pathway. Each page will need a patient ID sticker. Flip the page to Phase 1: On the first page of each pathway will be a section for comorbid conditions. Please list any conditions the patient has other than pneumonia, that may affect the care you are giving. This will help health records in coding this patient appropriately. You will then see two columns on the right hand side – each has “Date” at the top. Write in today’s date at the top of the first column. Under that, there are three columns, each corresponding to a shift for that 24 hour period. In the first column, write in the hours you will be caring for Jane. You will then use this column to initial as each task on that page is completed. (see a sample page completed). Use your corporate progress notes if you require further documentation.(see a sample page completed). Back to Start of Workshop Back to beginning of section NextBack

17. © 2004-2007 Grey Bruce Health Network Simulation Cont’d The rest of the page, and going on to the back of the page, lists the tasks that should be completed during this phase. For example, under assessments, Vitals should be taken Q4H &PRN, including O 2 Sats. Initial in the column to the right that corresponds to your shift as each task is completed. Some tasks are not appropriate for all patients or all time frames. In these cases, you can indicate an N/A and initial to show this. For example, if it is night shift, you will most likely not be teaching the patient, so under “Psychosocial Support/ Education”, you can indicate “N/A” and initial “Review Patient Pathway” and “Start Teaching Checklist”. (see a sample page completed)(see a sample page completed) This continues for each shift and each profession charting in the section they have completed, until the Patient Outcomes have been achieved. Back to Start of Workshop Back to beginning of section NextBack

18. © 2004-2007 Grey Bruce Health Network Simulation Cont’d On each day of all pathways, you will notice a referral to a Teaching Checklist and a Patient Pathway.Teaching Checklist Patient Pathway The Teaching Checklist should be on the chart and be filled in as topics are covered with Jane. This way the next nurse on shift will know what has been covered and can continue down the list.Teaching Checklist Back to Start of Workshop Back to beginning of section NextBack

19. © 2004-2007 Grey Bruce Health Network Simulation Cont’d The Patient Education Materials can be referenced to aid you in teaching. Also, the Patient Pathway should be referred to on a daily basis to help Jane understand the plan of care. At the end of each day, in the Discharge Planning section (last section of each page), you will notice it says “Assess Discharge Criteria Daily”. This means you will need to flip to the Discharge Criteria, on a daily basis, at some point during the day, and check if any of these goals have been met. If they have, initial and date them. Once all of these criteria have been met, Jane is ready to go home. This is repeated until the end of Day 2, or 48 hours since Jane has been admitted. At this time, the patient outcomes need to be assessed to see if they have been met. If they have, initial and date them, and move to Phase 2. If not, Jane needs to remain in Phase 1 until these indicators have been met. Back to Start of Workshop Back to beginning of section NextBack

20. © 2004-2007 Grey Bruce Health Network Simulation Cont’d If all the outcomes in Phase 1 have not been met by the end of the first 48 hours, Jane will need to stay in Phase 1 until they have been met. This is done by putting a photocopy of a blank Phase 1 page in the pathway and continue using it until that last outcome has been met.blank Phase 1 page The same is repeated for Phase 2, where the timeline is approximately 48 hours to achieve the patient outcomes for this phase. Let’s assume it is 24 hours into Phase 2, and Jane has now achieved all the patient outcomes. She can now skip the final day of this phase, and move directly to the Discharge Criteria. As soon as these criteria have been met, she can go home. Let’s take a look at the discharge criteria.discharge criteria Then look at the performance indicators. Were they met?. In Jane’s case, there was no smoking cessation advice/counselling given, because Jane is not a smoker. You can indicate this by ticking “N/A” next to this indicator. Back to Start of Workshop Back to beginning of section NextBack

21. © 2004-2007 Grey Bruce Health Network Simulation Cont’d If Jane is transferred to another hospital, there are instructions for this on the first page of the pathway (or on the back of the discharge criteria, for SBGHC users). Make sure the proper materials get forwarded to the receiving hospital, so they can continue using the pathway. Back to Start of Workshop Back to beginning of section NextBack

22. © 2004-2007 Grey Bruce Health Network Simulation cont’d If Jane is admitted to CCAC for Nursing services following discharge, the Cardiac Conditions Community Care Pathway is started. When Jane is discharged from hospital, the case manager will copy the Discharge Criteria and teaching checklist and send to the provider agency. If there is no case manager available in hospital that day, the nurse will forward the forms to CCAC Intake and Referral. When Jane is admitted for services, the clinical pathway is used for documentation, noting the admission outcomes that have been achieved and the discharge outcomes that were achieved.clinical pathway The client pathway is given to Jane to help her understand our goals in treatmentclient pathway The teaching checklist is used to ensure all aspects of teaching are completed before Jane is discharged.teaching checklist When Jane is discharged, a copy of the pathway is sent to the site champion to be forwarded to the Evidence-Based Care Program for evaluation. Back to Start of Workshop Back to beginning of section NextBack

23. © 2004-2007 Grey Bruce Health Network CHF Quiz 1. What are the inclusion/exclusion criteria for the CHF pathway? 2. When does the pathway start? Where do you find the orders? 3. This pathway has two phases. How do patients move from one phase to another? 4. What do you do if a patient remains in a phase longer than the 48 hours approximated on the pathway page? 5. What do you do with the patient pathway and patient education materials? 6. What do you do with the teaching checklist? Back to Start of Workshop Answers Back

24. © 2004-2007 Grey Bruce Health Network CHF Quiz Answers 1. What are the inclusion/exclusion criteria for the CHF pathway? All patients who are admitted with a primary diagnosis of CHF as defined by the New York Heart Association 2. When does the pathway start? Where do you find the orders? This pathway begins in emergency, unless the patient is directly transferred to the unit. You can print them directly off of the GBHN website, there is an icon on your desktop for this. 3. This pathway has two phases. How do patients move from one phase to another? When a patient meets the patient outcome indicators, he/she can move from one phase to the next. 4. What do you do if a patient remains in a phase longer than the 48 hours approximated on the pathway page? The patient needs to stay in this phase until all the patient outcomes have been met, so additional pages (blank) for this phase can be inserted into the pathway and used until the outcomes have been met. 5. What do you do with the patient pathway and patient education materials? These are given to the patient at admission and used for patient teaching and to help the patient understand what is happening during hospitalization. 6. What do you do with the teaching checklist? This should go on the chart and be filled in as topics are covered. The teaching checklist should be finished by the time the patient is discharged. If you have had difficulty with any of these questions, go back through the material on this pathway and/or the general pathway information in this workshop, or ask your Site Champion any other questions you have. Back to Start of Workshop Back