“The number of hospitalizations with any mention of heart failure tripled from 1,274,000 in 1979 to 3,860,000 in 2004; 65% to 70% of admissions were patients with additional diagnoses of heart failure.”1, p. 428 These are startling and compelling data, recently reported by Fang and colleagues from an analysis of the National Hospital Discharge Survey data from 1979 to 2004.1 Other significant findings from the analysis include:
- •Patients younger than 65 years had the lowest hospitalization rates, but had the highest relative increase during the study period.
- •More than 80% of heart failure hospitalizations occurred in the Medicare-aged population (>65 years), except during the study period 2000 to 2004.
- •The median hospital stay and the proportion of in-hospital deaths declined during the study time period, with the decline in mortality being larger among those with heart failure listed as the first diagnosis than among those with heart failure listed as an additional diagnosis.
- •There was an increase in the number of heart failure hospitalizations that resulted in transfers to long-term care facilities.
- •The proportion of hospitalizations with noncardiovascular disease as the first-listed diagnosis increased during the study period, suggesting that noncardiac chronic conditions are becoming more common in heart failure-related hospitalizations.
These findings have a tremendous impact on the work we do as nurses, as well as the work we do at The American Association of Heart Failure Nurses (AAHFN). In terms of the impact on nurses and nursing practice, I think there are 3 issues for us to consider. First, although there are increasing numbers of patients admitted with a primary diagnosis of heart failure, the appropriate management of the patient with acutely decompensated heart failure (ADHF) remains unclear and there are no clinical trials that have shown an improvement in all-cause mortality for patients with ADHF.2 General goals for treatment have been established,3 but how to effectively achieve these goals has not been determined. Further, although criteria for hospital discharge have been published,3 these are primarily based on expert opinion, and we still do not know the optimal timing of discharge. Patients' subjective symptoms are often used as markers for discharge readiness and these are not consistently reliable indicators of stability.2
Having said all of that—at least when patients are admitted with a primary diagnosis of heart failure they get treatment directed at their heart failure, albeit treatment that is lacking in strong evidence. What about the patient admitted with an additional diagnosis of heart failure? These patients usually do not have heart failure specialists seeing them and their chronic heart failure treatment often gets “undone” by well-meaning practitioners taking care of the patients' other health problems. The Fang et al.1 article highlights for us how this will be a continuing problem, as they found that 65% to 70% of hospital admissions for heart failure occurred among those patients with an additional (not primary) diagnosis of heart failure.
The second issue that comes to mind is the appropriate placement of nurses in a well-designed care system for these patients—patients with either a primary or additional diagnosis of heart failure. Nurses with the skill-set necessary to care for acute heart failure patients are typically found in telemetry, step-down, and coronary care units, and these areas will continue to need well-trained nurses to care for patients with a primary diagnosis of heart failure. But what about the 2 million patients with an additional diagnosis of heart failure who are admitted to other, noncardiac areas of the hospital? And, further, what about the increasing numbers of heart failure patients that are being transferred to long-term care facilities after hospitalization?1 These patients may or may not receive a cardiologist consultation during their stay, but they likely do not receive care from a trained heart failure nurse. What is the best way to connect with these patients to review and manage their heart failure care? Case managers or advanced practice nurses that can practice across specialties and locations? Providing training in heart failure care to all nurses in medical-surgical and specialty practice areas as well as nursing staff (often not registered nurses) in long-term care facilities? Redesigning care systems so that patients with heart failure are followed by a consistent set of caregivers rather than different caregivers at different sites in the care continuum?
The third issue for nurses and nursing practice is the pressing need for research targeted to the above noted issues. The whole area of discharge readiness is wide open for nurse-led studies to identify and validate objective discharge criteria for patients with either primary or additional heart failure diagnoses. Investigating transitions in care for heart failure patients and evaluating educational models for nonheart failure nurses are other areas for nurse-led studies.
In terms of the data's impact on AAHFN, there are 2 major issues for us to consider as an organization. First, we need to keep asking, “What exactly is a heart failure nurse, where does he or she practice, and what does he/she need to know in order to take better care of patients?” The fact that the majority of heart failure-related hospital admissions are not for the primary diagnosis of heart failure indicates that most patients will not be on cardiovascular units. We have to expand our outreach to query and educate medical-surgical nurses as well as nurses in other specialties (endocrine, pulmonary, nephrology) and in other locations (long-term care facilities) about appropriate heart failure care.
The second issue for AAHFN to consider is that of certification. Certification in a nursing specialty denotes achievement of professional competency in that area and indicates to professionals, patients and families that the individual has met a national standard. In our strategic plan, AAHFN has already established the importance of developing certification for heart failure nurses. The data from this study1 validate the importance of this initiative and lend support to perhaps extending the concept of certification beyond traditional cardiovascular nurse boundaries.
The American Association of Heart Failure Nurses