New Cedars-Sinai clinic to specialize in CHF

A new heart failure center under construction

(Editor’s note: The following article features the start of a heart failure clinic in an urban California setting. See CHF Disease Management, January 1999, p. 26, for more on a fully operational CHF management center at the University of Michigan in Ann Arbor.)

Another urban medical center is taking a multispecialty approach to treating CHF patients, with the hopes of joining the ranks of established centers at the University of Michigan and the Mayo Clinic.

Nurses, doctors, pharmacists, physical therapists, social workers, dietitians, and other caregivers are banding together with health care scientists to form the Advanced Heart Failure Clinic at Cedars-Sinai Medical Center in Los Angeles.

"The idea of this specialty clinic really, really works," says Ellen Daroszewski, RN, PhD, ACNP, a Cedars nurse practitioner. Caregivers get a full picture of each patient’s illness and can get him or her involved with controlling symptoms.

"Essentially, we’re trying to take care of the largest reason for hospitalization," adds Americo Simonini, MD, cardiologist for Cedars’ new CHF clinic. When patients lose control of their condition, they often end up in the local emergency department (ED) for help.

"Ninety percent of these patients who go to the ED will be admitted," Simonini says. In the next 10 years, the number of CHF patients could double from today’s count of about four million; assembling caregivers into multiprofessional CHF centers could be a growing trend for big city hospitals.

An even greater concern than readmission, Daroszewski says, is getting a quick jump on the disease when it is developing. Half of the CHF patients would be expected to die within five years of the onset of the disease unless aggressive action is taken. When the condition gets a head start on a patient of 40 or 50, "that’s a young person dying," she says.

The key is to get patients involved with a heart failure program. Cedars, like other centers, may get patients on referral from local primary care physicians, cardiologists, or HMO. Patients may have been told by their doctors they have CHF and come in on their own.

Patient workup: Getting to know you

Once the patient comes through the door and communication is established with the current physician, Daroszewski says an extensive orientation period begins. Here are the major stages:

1. Get a full picture of the patient’s disease.

Daroszewski first collects all the tests, records, files, and other information that the patient already has. Sometimes, a patient’s symptoms suggest an echocardiology study is needed to look for a malfunctioning valve, for example. If there are signs of arrhythmia, a Holter monitor may be required.

"We fill in the blanks," she says. Perhaps the patient never had an exercise stress test, and one could be helpful to determine the extent of heart failure. "This test really gives us a good indication of functional status." Cedars also does pharmacologic stress tests with Persantine or Dobutamine for patients who are unable to do any exercise for the traditional test.

2. Get an initial evaluation of the patient.

"Here’s where we get a good idea of the status of the patient’s heart," Daroszewski says. First comes an attempt to determine what caused the CHF, and it also gives hints on what corollary services may be needed.

Since eight in ten cases are caused by some sort of ischemic heart disease, there may be need to control the basics like cholesterol, obesity, or smoking. Alcohol-related cases may indicate other programs are needed to stop habitual drinking. Family history of heart disease is checked as well as other causes of CHF such as determining if it’s idiopathic.

A major part of this evaluation is risk stratification, where the staff tries to determine if the heart failure is stable, improving, or getting worse. This is where caregivers try to determine how long the patient could be expected to live without intensifying treatment.

It’s a lot of collecting. "But that is only the start of the job," she says.

Once the team knows what’s going on with the patient and what will happen if the CHF is left uncontrolled, Daroszewski talks the patient through the proper course of treatment. But whether the case calls for drug therapy, transplantation, or other surgery, the follow-up to the risk assessment has to be comprehensive.

"We look at the patient’s whole life," she explains. (See related story for more details about following up on patient assessment, at right.) All these factors have to be taken into account to make sure the patient understands the treatment strategy and will continue to help keep the CHF under control:

    - level of education;
    - financial situation and health care coverage;
    - willingness to comply with the treatment and adjust lifestyle;
    - current quality of life;
    - comorbidities;
    - cultural or ethnic background;
    - cardiorehab;
    - home assessment;
    - dietary requirements.

Daroszewski says Cedars is developing a program where a staff member goes to the patient’s home to assess what may be needed, like accurate scales.

Patients also are managed by phone and receive at least one monthly call from the Cedars staff who will ask about these factors:

    - ability to walk;
    - weight fluctuations;
    - sleep patterns;
    - heart failure concepts.

The nurse may ask "Tell me about your medicines. Do you remember what they do?"

"Some patients are very good on their own," she says. "Others need a lot of coaching. We also tell patients that we care about them, that we want them to stay well and do what they need to do, and that all this stuff matters."

Status of the program

Daroszewski says Cedars has 100 patients to assess and work into the system. The staff are continuing to develop clinical protocols. She and Simonini are scheduled to have the program fully operational by the end of this summer, although they probably will be refining it for the rest of the year.