CHF Protocols

My company has been hot on this CHF protocol stuff. In my state we can't have any standing orders therefore we don't have any policies in place regarding IV Lasix and such.

All admits with a diagnosis of CHF are started on CHF protocols

- 2gm Na diet

- Daily weight. MD notification of anyone with a 2lb gain in a day or 4lb in a week. Education to nurses that this is the time to ask for that IV Lasix, etc &/or request BTNP

- Daily vitals, edema assessment, respiratory assessment

- Fluid restrictions as ordered (which is a joke because I can't get anyone to follow this well including the families who are constantly bringing in large McDonald's pop, etc despite educating them as well).

- O2 as ordered

I'm thinking of marking the chart spines with a heart sticker and a date to represent day 31 just as a visual reminder that we are trying to prevent the readmits on this particular resident.

I've spent a lot of time educating nurses on the importance of preventing the readmits and the potential impact it will have if we tick off our referral source by costing them big $$. We had a great success couple months back when one of my star nurses went to bat and argued with the MD that she was as capable as an ER nurse at administering IV Lasix and "no use to send to hospital when I can do it right here". The MD gave in and gave her the orders she wanted and the resident stayed in the facility and did great. Her actions got written up in the corporate newsletter as a success story and this just motivated the rest of my team to get on board.

I think it also takes a lot of effort in educating the families. Sometimes I'm not sure the hospital &/or MDs are doing their part in educating the families on the disease process and what the expectations should be. I just cringe when I see this 95 year old man, wheeled in on a gurney, oxygen on 4L, short of breath just with conversation, full code and the sweet daughter following behind with a Big Mac, fries and gigantic Coke because Daddy didn't get lunch before the transfer.

To CCM and Nascar - I'm impresed that you're allowed to administer IV meds (not just ABTs) where you are. Maybe your areas are just more progressive than where I've been. All my past facilties were very stodgey about IV meds. I mean, I'm talking about simple IV dextrose boluses!! Sheesh - I've pushed for IV hydration with little success at some places!

Granted, you would really have to be lucky to have a strong nurse such as Nascar did. I have an ancient history of critical care, and I'm good with IV starts. I would have no qualms pushing some select IV meds, esp in some crucial situations, but I know that not to be so of very many of my co-nurses without that background. I guess that I've just not worked at places that were very proactive.

Maybe now is the time for some LTC/SNFs to move into the 21st century.

I work on a skilled care unit in a hospital and we don't even give IV push meds. We remind the MDs that if the patient really needs IV push meds, they don't belong on our unit. Usually they will switch to PO meds unless the patient really needs to be transferred. I'm usually so busy that I don't have time to monitor patients that are getting IV push meds.

I work on a skilled care unit in a hospital and we don't even give IV push meds. We remind the MDs that if the patient really needs IV push meds, they don't belong on our unit. Usually they will switch to PO meds unless the patient really needs to be transferred. I'm usually so busy that I don't have time to monitor patients that are getting IV push meds.

Interesting. I wonder since you are actually in a hospital and presumably part of the hospital system how it works with the 30 day readmission?

We have a very competitive LTC system in my area with 2 beautiful brand new facilities recently opening. It's pretty clear to all of us locally that if we want the referrals we WILL prevent the 30 day readmissions or they will send referrals to the competitor who can.

I have what might be a silly question regarding diets. In most of the homes I have worked in, if a resident is admitted with a specific diet like 2gm Na diet or 1800 calorie Diabetic Heart Healthy Diet for example, the dietary manager and/or DON has made the statement that they don't do "specialized diets" so they are put on a NAS or NCS diet. The answer to this is "It's too complicated so everyone on restricted diets get either NAS or NCS or a combination NAS/NCS diet." Others have expressed the fear of getting in trouble with surveyors if everything is not measured out and calculated perfectly.

Wouldn't this defeat the purpose of a specialized diet? I have always wondered about this and am seriously curious.

Edited to add: We have been instructed to do everything we can in the home if someone takes a turn for the worse and that includes IV Lasix, O2, suctioning, etc... Sending them out is a last resort. If the nurses cannot stabilize the resident in the home, then they get sent out.

I have what might be a silly question regarding diets. In most of the homes I have worked in, if a resident is admitted with a specific diet like 2gm Na diet or 1800 calorie Diabetic Heart Healthy Diet for example, the dietary manager and/or DON has made the statement that they don't do "specialized diets" so they are put on a NAS or NCS diet. The answer to this is "It's too complicated so everyone on restricted diets get either NAS or NCS or a combination NAS/NCS diet." Others have expressed the fear of getting in trouble with surveyors if everything is not measured out and calculated perfectly.

Not silly at all. I've been around this business longer than I care to admit and it's one gigantic pendulum. Way back in the day we had all these specialized diets for everyone. Later someone came along and said "well that's stupid - get rid of all that junk, this is their home". Now we're swinging back the other way to specialized diets. If you don't like it (and not sure I do as no one will follow it anyways) wait around long enough and it will go back the other way.

What was your patient to nurse ratio when you were at the facility pushing IV Lasix? This is going to become common as we see more CHF patients admitted to skilled nursing facilities/

rehab units.