Medication Adherence Term Paper

Interdisciplinary team for safe transition of heart failure patients

Interdisciplinary team for safe transition of heart failure patients

Introductions

The 30-day re-hospitalization penalty for hospitals has led the healthcare professionals to opt for an interdisciplinary transitional care approach in order to provide safe and efficient transition for patients with heart failure from hospital settings to home. Heart failure (HF) is a chronic condition and requires a lifelong treatment. 14% of the Medicare beneficiaries suffer from HF. The re - hospitalization rate of HF has been noted to be 10 to 19% within 14 days and 50% within 90 days. Such readmissions have resulted in heavy Medicare bills of $333 billion in 2006 and account for 7.4% of the annual Medicare bills. Steps to prevent unplanned re-hospitalization could save $12 billion annually (Stauffer et al., 2011). In 2013, the Centers for Medicare & Medicaid Services reported that nearly 2000 hospitals were facing penalties of 1% of the Medicare annual bill for frequent re-hospitalization. The reason for re-hospitalization was determined to be poor communication between the hospital staff and the caretaker of the patient, inadequate follow-ups, inadequate understanding of the mediations and reduced awareness regarding non-adherence to diet, medication and physical activities (Rennke et al., 2013). Current transitional care tactics include tele monitoring, remote monitoring, frequent follow-ups, patient education, patient counselling, etc. to ensure adherence and reduce re-hospitalization incidences (Albert et al., 2015).

Older patients with HF require medications that caters for their aging renal and cardiac organs. For this purpose, HF patients are usually prescribed diuretics, beta-blockers and angiotensin- converting enzyme inhibitors (ACEIs). Such older patients could also have comorbidities and might be taking medications for those problems, increasing the chances of possible drug interactions (Jugdutt, 2014).

Beta-adrenergic blockers

Beta-adrenergic blockers or beta-blockers are prescribed to older HF patients due to the possibility of occurrence of bradycardia (slow heartbeat) and AV- node conduction disorders associated with their aging sinus node pacemaker cells. Beta-blockers are prescribed in low to intermediate dosages for optimal activity. The patients are monitored using an electrocardiogram (ECG) after commencing and each dose change during the beta-blocker therapy. It is normal for the patients to feel cold hands, dizziness and fatigue. Most patients do not experience any side effects. However, some patients could experience bradyarrhythmias, which is a contraindication for use of beta-blockers and an indication for considering permanent pacemaker implant (Jugdutt, 2014).

Diuretics

HF patients suffer from water retention in the body, as the heart is unable to pump enough blood, leaving the person bloated. Another reason for edema is that with age, the kidneys lose their ability to filter properly, leading to chronic kidney disease and water retention. Such a dysfunction could affect the electrolyte balance in the body. Therefore, HF patients are prescribed diuretics to help the kidneys remove more water from the body. However, patients undergoing diuretic therapy often experience dehydration due to an impaired thirst mechanism, which could lead to over-diuresis. Over diuresis is marked by over-expulsion of water from the body, leading to reduction in potassium, sodium and magnesium in the body along with electrolyte imbalance. To prevent renal impairment by the use of diuretics, it is imperative to set up a stringent follow up to assess renal function, monitor electrolyte level and check the efficacy of the medication for edema. Some patients are prescribed potassium supplements, if they are young. However, older patients usually have to compromise with reduced potassium level and deteriorating renal functioning and residual overload (Jugdutt, 2014).

Angiotensin converting enzyme inhibitors

ACEIs and angiotensin-receptor blockers (ARBS) prevent the formation and action of angiotensin associated blood vessel constriction, respectively and help in the reduction of blood pressure. Side effects of ACEIs and ARBs include progressive renal dysfunction, low blood pressure and increased potassium in blood. When these drugs are used in conjunction with diuretics, the occurrence of over-diuresis could worsen renal impairment. Other common side effects include cough and allergic reaction. Increases in serum creatinine are a contraindication for use of ACEIs and ARBs (Jugdutt, 2014).

Common drug interactions

The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in older patients with HF and renal impairment has been associated with kidney failure. In addition, NSAIDs revert the remedial effects of ACEIs, ARBs, beta blockers and diuretics. Drugs used for arrhythmias have been shown to exacerbate the effects of beta-blockers. ACEIs and ARBs when administered in conjunction with an aldosterone antagonist could lead to increased potassium levels in the blood in older HF patients. Studies have shown that it is normal for a HF patient to take more than 10 medications per day for various physiological issues (Jugdutt, 2014).

Diet-drug interaction

Food supplements such as chaste tree and ephedra increase toxicity associated with beta-blockers. Nettle, pumpkin seeds, dandelion and black cohosh cause over-diuresis by increasing the effect of diuretics (Jugdutt, 2014).

Role of registered nurses (RN) and interdisciplinary team in medication adherence

Cognitive impairment associated with age and large amounts of medications are some of the reasons for non-adherence. One of the strategies for medication adherence should be simplification of the prescription in terms of amount of medication and the number of times it is taken. RN could help in medication adherence by educating the patient and the caregiver on the prescription, changes in made in the prescription, non-pharmacological alternatives, if possible and encourage use of pillboxes and other similar mediation aids (Jugdutt, 2014).

Dietary Modifications

Dietary modifications fall under the non-pharmacological treatments for patients with HF. The major focus here is on reducing sodium and fluid intake as a part of self-care behavior recommendation. Sodium causes fluid retention in the body, leading to edema. Studies show that on an average an American consumes 3.7 g of sodium/day. Patients are advised to reduce their salt intake to 2 to 3 grams/day and water intake to 1.5 to 2 liters/day. Those with severe HF and above 50 years of age are recommended a restricted salt intake of 1-2 g/day. Inadequate cardiac output leads to HF and does not provide enough blood to the kidneys. Such a physiological state causes the activation of the renin angiotensin aldosterone system (RAAS) and the sympathetic nervous system, which cause vessel constriction and elevation of blood pressure. The effect of sodium restriction has not been clearly studied in people of different races and cultures. The role of reduced sodium diet has also not been evaluated. Restricted sodium intake has also been associated with activation of the RAAS, creating a vicious circle of contradicting dietary and pharmaceutical recommendations (Gupta et al., 2012). A review of literature shows that a reduced sodium (2-2.4g/day) and fluid intake decreases edema and the excretion of sodium in the urine while improving quality of life. Studies also show that too less of sodium intake could lead to adverse effects. Therefore, patients with HF need to take salt that is optimal for their body function. Researchers believe that cultural differences and culinary traditions add to the difficulty of diet adherence in many HF patients and thus, recommend individualization of the diet change based on these factors (Philipson, Ekman, Forslund, Swedberg & Schaufelberger, 2013).
As a RN, it is necessary to educate the patients regarding the strict diet modifications for safe transition. However, one of the obstacles that a RN might face is non-adherence or partial adherence to the diet. Patients could complain of loss of appetite and the unpalatable nature of the food due to low salt and this might indirectly affect their quality of life. The patients on low fluid diet could complain of thirst. It is necessary to teach the patients how to spread their fluid intake through the day to minimize thirst and ways to make their food enjoyable in order to retain the required calorie intake (Philipson et al., 2013).
A dietician is the best interdisciplinary team member to assist the patient in safe transition into a home setting. A dietician could collaborate with the RN in teaching the patients and their caretakers regarding the effects of sodium along with an individualized diet plan for ease of adherence. Studies have shown that telemonitoring through unannounced phone calls to the patients at regular intervals along with home visits help in adherence and monitoring (Philipson et al., 2013).

Physical activity

Studies have shown that patients with HF could benefit from aerobic exercise by initiating the reversal of muscle wasting, left ventricular remodeling, ventilator inefficiency and endothelial dysfunction with an 11% reduction in all-cause mortality. Exercise is prescribed based on frequency, intensity, time and type (FITT) (Conraads, 2012). The American Heart Association and the American College of Sports Medicine have listed the physical activities that the elderly can perform without inducing other physical complications. The aim of the exercise would be to increase the heart rate. Depending on the physical ability, a moderate intensity exercise would translate to a brisk walk or slow walk for 30 minutes 5 days a week or for 20 minutes 3 days a week. Benefits of exercise include improvement in balance and reduced risk of falls; retention of bone mass and a slower deterioration of bone minerals; improved immunity; healthy gut and gastrointestinal functioning; and, improvement in quality of life (Jugdutt, 2014).
Non-adherence is a common factor observed in older HF patients. According to the World Health Organization (WHO), the reasons for non-adherence can be divided into five categories. Patient-related reasons for non-compliance to exercise regime included age, education, status, socio-economic level, transportation problems, lack of time and motivations and lack of awareness regarding the benefits Healthcare team reason includes lack of proper expertise in training the patients. Socio-economic reasons include lack of support and resources for the patient. Health condition related reasons include severity of the HF condition and the presence of co-morbidities that prevent adherence. Therapy related reasons include inability to comply with the exercises in daily life and lack of relevance of the exercises to the patient (Conraads, 2012).
It is the RN’s responsibility to ensure that the patient adheres to the exercise regime at home. One way to do that would be to collaborate with a physical therapist who could make the physical activity more patient-centric. It would be advisable to screen for depression where the patient exhibits lack of motivation and set up a counselling with a psychologist. In case of socio economic reasons, a social worker might be able to resolve such issues by understanding the patient’s belief regarding exercise and needs. The interdisciplinary team members could monitor the adherence through telemonitoring, unannounced home visits and planned rehabilitation schedule (Conraads, 2012).

Assessing the effectiveness of the interdisciplinary team in the management of HF patients

Literature shows that transitional care models use interdisciplinary or multidisciplinary discharge team to ensure a safe transition of patients with HF from acute hospital settings to home, where nurses played the role of coordinating the various team members (Albert et al., 2015). Other team members involved are a pharmacist, dietician, social worker, physical therapist and psychologists who collaborated with the primary physician and the RN to address a specific intervention. The multidisciplinary team aims to provide a seamless care for HF patients by coordinating the various forms of care throughout the chain of care. Typically, the components of a multidisciplinary care are appropriate diagnosis at the healthcare facility by the primary physician; medical management by nurses; education and counselling by psychologists, social workers, pharmacists and dietician; discharge planning by RN and physician; constant monitoring after discharge by all members of the team; attention to behavior by psychologist and RN; increase access to healthcare; exercise regime secluding by physical therapist (Obiegło & Uchmanowicz, 2012).
As part of safe transition, the team must provide general advice to the patient and their family regarding the manifestation of HF and its causes, how to recognize the symptoms and list of actions, the rationale behind the treatment plans, the importance of adherence to diet, medication and physical activity, prognosis and advanced instructions. The pharmacist and RN must educate the patient and the family regarding the various drugs, their components, their intended action and side effects along with instructions on how to tackle missed doses, tips for adherence and recognizing signs of toxicity. The dietician, psychologist and the RN must educate the patient and their family on the importance of sodium restriction, fluid control, refraining from smoking, refraining from alcohol and general tips on adherence. The cardiologist, the physical therapist and the RN must highlight the need for physical activity, ways to conserve energy to fight fatigue, rehabilitation programs, instructions on travel, other physically demanding activities and tips for adherence. The patient must be educated on self-monitoring, list of expected symptoms and adverse symptoms and a list of actions to be taken during occurrence of severe symptoms (Obiegło & Uchmanowicz, 2012). The success of a multidisciplinary team could be gauged by the reduction in the rate of re-hospitalization of the patient for the longest time possible in addition to adhering to all required regimes, decreased mortality by HF and improvement in quality of life (Obiegło & Uchmanowicz, 2012).

Conclusion

Currently there is no well-defined transitional care to prevent re-hospitalization for HF. However, the best approach model would be the one that provides holistic and patient-centric care for the entire duration of a patient’s condition. Such a model would be a collaborative effort from members and experts of various disciplines who strive to provide a safe transition to the patient using advanced monitoring systems.

References

Albert, N. M., Barnason, S., Deswal, A., Hernandez, A., Kociol, R., Lee, E., & White-Williams, C. (2015). Transitions of Care in Heart Failure A Scientific Statement From the American Heart Association. Circulation: Heart Failure, HHF-0000000000000006.
Conraads, V. M., Deaton, C., Piotrowicz, E., Santaularia, N., Tierney, S., Piepoli, M. F., & Jaarsma, T. (2012). Adherence of heart failure patients to exercise: barriers and possible solutions. European journal of heart failure, 14(5), 451-458.
Gupta, D., Georgiopoulou, V. V., Kalogeropoulos, A. P., Dunbar, S. B., Reilly, C. M., Sands, J. M., & Butler, J. (2012). Dietary sodium intake in heart failure. C
Jugdutt, B. (2014). Aging and heart failure: Mechanisms and management. Dordrecht: Springer.
Molloy, G. J., O'Carroll, R. E., Witham, M. D., & McMurdo, M. E. (2012). Interventions to enhance adherence to medications in patients with heart failure a systematic review. Circulation: Heart Failure, 5(1), 126-133.
Obiegło, M., & Uchmanowicz, I. (2013). The role of interdisciplinary care in heart failure. Pol Przegl Kardiol.15(4): 278-282
Philipson, H., Ekman, I., Forslund, H. B., Swedberg, K., & Schaufelberger, M. (2013). Salt and fluid restriction is effective in patients with chronic heart failure. European journal of heart failure, 15(11), 1304-1310.
Rennke, S., Nguyen, O. K., Shoeb, M. H., Magan, Y., Wachter, R. M., & Ranji, S. R. (2013). Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. Annals of internal medicine, 158(5_Part_2), 433-440.
Stauffer, B. D., Fullerton, C., Fleming, N., Ogola, G., Herrin, J., Stafford, P. M., & Ballard, D. J. (2011). Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls. Archives of internal medicine, 171(14), 1238-1243.