CHF Home Health Nurse Guidelines

The following are excerpts from the nursing guidelines, taken from a presentation to the Home Health Nurses Association and the National Association of Home Care during a recent conference in Dallas.

Foundation for Guidelines

Purpose: The guidelines were developed to provide nursing practice parameters for cardiac home care that:

1. Assist home care nurses and agencies in delivering comprehensive cardiac care that focuses on promoting periods of wellness, encouraging self-care management, and preventing disease progression using the nursing process as the framework.

2. Outline specific competencies of proficient and expert cardiac home care nurses.

3. Identify practice parameters that can be used to quantify clinical outcomes and measure improvements in cost effectiveness.

4. Offer an initial practice framework that can be the basis for future research.

Foundation for Guidelines Consensus Panel

1. Developed by a group of expert cardiac home care nurses

2. Peer-reviewed at two levels:
— HHNA
— Peer reviewers selected by HHN Journal

Guideline Assumptions

1. Patient population is comprised of cardiac patients in the home.
— recovering from myocardial infarction (MI)
— recovering from coronary artery bypass graft (CABG)
— recovering from an exacerbation of congestive heart failure

2. Medical plan of care is set by the physician.

3. Plan of care includes the nursing plan of care, which differs from the medical treatment plan.

4. Evaluation of the medical treatment plan
— a collaborative effort between nurse and physician, comparing current plan with recommended evidence-based guidelines

5. Foundation of nursing practice
— patient symptoms and needs drive practice, not reimbursement guidelines

6. References
— guidelines are based on the most current evidence-based clinical information
— periodic updates are required

7. Peer reviewed

8. Individualization
— Guidelines frame recommended cardiac home care nursing practice from which to craft an individualized patient plan of care

9. Recommended encounters for goal attainment (REGAs)
— "Encounters" replace the term "Visits"

10. The professional nurse
— Care provided on the guidelines is administered by a registered nurse who meets the recommended competencies

Recommended Competencies

1. The autonomy of home care nursing practice demands that the registered nurse practice alone in an environment where timely clinical judgments are critical to positive patient outcomes.

2. The guidelines were predicated on the principle that nurses providing home care services to cardiac patients be either proficient or expert nurses. (See Benner’s levels of nursing expertise in #3.)

3. Benner’s levels of nursing expertise
Novice: No background understanding
Advanced beginner: Demonstrates marginal acceptable performance
Competent: Can clinically decide which attributes in a situation are most important
Proficient: Has an intuitive grasp of the situation based upon a deep background understanding
Expert: Tests and refines theoretical and practical knowledge in actual clinical situations

• The proficient cardiac home care nurse
— Meets basic competencies of a proficient home care nurse
— Provides cardiovascular assessment, diagnosis, intervention, evaluation, and clinical decision making
— Has education, training, and experience specific to cardiac illness as outlined by the following qualifications:

    (1) RN licensed in the state where practicing
    (2) BSN preferred
    (3) minimum of 3-5 years cardiac nursing experience, additional 2 years in home care preferred
    (4) BCLS certification
    (5) successful completion of a core competency exam for the proficient cardiac nurse (score of 80% or better)

• The expert cardiac home care nurse
— Has met all competency requirements of both the competent and proficient cardiac nurse
— Has advanced education, clinical experience and expertise
— Achieved a level of expert clinical practice and patient disease management as outlined by the following qualifications:

    (1) RN licensed in the state where practicing
    (2) minimum of 8 years cardiac nursing experience, with 3-5 years home health nursing experience preferred
    (3) BSN minimum (MSN preferred)
    (4) BCLS certification
    (5) successful completion of a core competency examination for the expert cardiac nurse, which includes ECG interpretation (score of 80% or better)

Example Guideline 1:

History and assessment of all cardiac patients in the home

Goals

1. Every cardiac patient referred for home care receives a complete cardiac history and assessment from the cardiac home health nurse.

2. The patient receives a cardiovascular history and assessment at subsequent home care encounters.

Outcome 1a: Patient communicates a cardiovascular health history at home care initiation.

• Action. The nurse obtains a history of:
— disease
— diagnostic procedures
— CV risk factor inventory
— surgical interventions
— medication management
— utilization of community resources

Outcome 1b: Patient receives a cardiovascular physical assessment at home care initiation.

• Action. The nurse performs
— inspection
— auscultation
— palpation (skin temperature, turgor, pulses, edema)
— edema measurement

    (1) measure ankles bilaterally and abdominal girth
    (2) use edema scale (as shown below)

Outcome 1c: Patient receives baseline electrocardiogram (ECG) assessment at home care initiation.

• Action. The proficient or expert cardiac nurse assesses the patient for the following indications for single-lead ECG assessment:
— presence or recent history of arrhythmia
— inotropic infusion therapy
— irregular pulse
— post-myocardial infarction; 5 days or less
— new complaint of dizziness/lightheadedness
— new medication regimen of digoxin or antiarrhythmics

NOTES

Patients complaining of chest pain that is unrelieved with sublingual nitroglycerin should be instructed to call EMS.

It is not recommended that time is used to complete a 12-lead ECG assessment.

ECG Policy

1. Home ECG monitoring is completed to assess the electrical functioning of the myocardium in an unstable or recovering cardiac patient population.

2. ECG monitoring is NOT intended to be a diagnostic tool for the patient experiencing angina or coronary ischemia.

Nurse competency for home single-lead ECG monitoring

1. 3-5 years cardiovascular nursing experience, which includes ECG interpretation, prior to entering home care.

2. Documentation on file with the home care agency demonstrating ECG interpretation skill.

3. ACLS is not recommended as acceptable certification for cardiac home care competency.

4. Each home care agency should create its own ECG competency exams.

Home ECG monitoring procedure

1. Obtain ECG rhythm status at time of referral.

2. Baseline single-lead documentation made on chart.

3. ECG monitor is placed on patient at the beginning of the home care encounter.

4. Minimum of two ECG rhythm strips should be printed within 72 hours of patient referral and prior to discharge.

5. ECG rhythm documentation should include patient name, date, time, heart rate, PR interval, QRS interval, and name of rhythm.

6. Patient’s prescribing physician is notified of any change in ECG rhythm.

Outcome 2a: After the initial health history is completed, the patient is asked assessment questions during every subsequent home care encounter.

• Action: The nurse asks about:
— patient status worsening, improved, or unchanged since last encounter
— symptoms experienced since last encounter
— medication problems since last encounter
— health professional visits since last encounter

Outcome 2b: Every home care encounter after the initial encounter includes an overall cardiovascular physical and psychosocial assessment as outlined in Outcome 1b.

Outcome 2c: Single lead ECG assessment during subsequent encounters.

• Action: The nurse will complete single-lead ECG assessment on patient with identified arrhythmias from the previous encounter or with the following symptoms:
— lightheadedness/dizziness
— palpations/heart pounding
— change in pulse from regular to irregular

Outcome 2d: The patient receives ongoing assessment of compliance with the therapeutic plan.

Source: Cindy Bolin, RN; Kelly Hayes, BSN, RN; Ann Frantz, BSN, RN.