Congestive heart failure is a very common reason for hospitalization, with over 1 million congestive heart failure (CHF) admissions per year; readmission rates are 30% at 30-60 days. Identifying methods to reduce the frequency of hospitalization and the associated costs are critically important.
Early exercise training may be useful in reducing morbidity and mortality in CHF. Aerobic and strength training are both key as muscle strength is a key predictor of long term survival, better than peak VO2.
The 6 min walk test is commonly used to measure functional capacity. A result under 300 meters is associated with increased mortality. The test is sensitive to changes in cardiac function, and a difference of 99 feet is considered the minimal improvement of clinical importance according to Ethel Frese.
There have been substantial improvements to Ventricular Assist Devices (VAD) since there original introduction as bulky external devices that required a suitcase-sized support device to be moved with the patient. VADs were originally thought of almost exclusively as a bridge to cardiac transplantation. Chris Wells shared that they may now be a bridge to recovery or even destination therapy, that is a long-term management strategy.
Most are left ventricular assist devices (LVAD), although right ventricular units also exist. All are independent of the cardiac rhythm evident on the EKG. Consequently, one can do therapy when the patient appears by EKG to be in ventricular tachycardia, ventricular fibrillation, or asystole. VADs require a variable range of anticoagulation. All are susceptible to infection, bleeding, thrombosis/stroke and mechanical failure.
The prevalence and pathopshiology of congestive heart failure is 25% of patients with heart disease. Evidence based dietetics practices approved by the American Dietetics Association (ADA) have been developed to guide the medical nutrition therapy for patients with heart failure.
Cindy Cassel educated the audience on how the ADA uses workgroups to develop disease specific guidelines, which recommend what should be done in terms of nutrition and then how it should be delivered. In addition, the ADA has developed a guideline rating system that helps guide the dietician and patient on the strength of the guideline based on evidence base.
The ADA recommends that the treatment of heart failure symptoms should be based on a comprehensive nutrition assessment to maximize adequate intake and control for the symptoms of disease. In general the nutrition assessment of a heart failure patient should focus on protein needs (should be higher to save muscle) and energy needs.
Many positive changes in technology and innovation of science have been injected into the experience of health care over the last decade. Dr. Smith cautioned that the good has also brought challenges like less time, less communication, less trust, and more opportunities for things to go wrong.
In addition, family issues have become a barrier to taking care of the rehabilitation patient. Dr. Smith has experienced that the family has less capacity to be caretakers because of the changes in family structure. Dual income couples, more singles, geographic distance between family members has increased, and definition of family has changed: these factors make it harder for family members to be effective caretakers and create stress.
Dr. Pandya outlined identified the objectives of her talk to review the goals of glycemic control: One size does not fit all, review the current guidelines from several national organizations for cardiovascular risk, and review best practices for diabetes management.
Diabetes is a head to toe disease: Retinal disease, stroke, nephropathy, neuropathy, large and small vessel disease of the extremities and this emphasizes the range of diabetes impact.
There are many potential barriers to improved management of diabetes: Institutional challenges, staff/practitioner resistance, and complexity of medication regimens and all may negatively impact diabetic control. Yet, there are several basic principles that apply to diabetes management, and must involve an inter professional clinical team:
Maintaining functional status is the over arching goal of all interventions applicable to diabetes management.
Cocheco Cardiopulmonary Recovery Program Kindred Transitional Care and Rehabilitation Dover, NH.
Presented at the 2011 Kindred Healthcare Clinical Impact Symposium by Linda Dubois, RN, AND.
The issue of chronic critical illness or Post Intensive Care Unit Syndrome (PICS) is of great importance in the managment of patients in the ICU. There are many additional synonyms for the problem, and the number of names for syndrome demonstrates lack of critical understanding of the syndrome.
Why is this an important concern? Acute respiratory failure results in 1.1 million ICU admissions needing mechanical ventilation annually. There are 400,000 ICU deaths/yr with resp failure; hospital mortality: 37%. The cost of this care is substantial and rising; total health care costs total 17.6% of GDP in the US.
The key questions to be answered about early rehab care in the ICU are:
Morris points out fiscal considerations of ICU rehabilitation are a potential barrier and historically, the fear of early movement of ICU patients may also fuel reluctance to intervene.
Activities of physical therapy and rehabilitation are critical in improving outcomes for the patient with heart disease. The areas to be focused on include aerobic exercise training, resistance/strength training, and inspiration muscle training. These may have important impacts on measures such as hospitalization, quality of life (QOL), and even survival. One of the first steps is understanding your risk for heart attack. Cahalin urged the audience to visit the American Heart Association's website for heart attack risk factor assessment and asked that we have our patients do the same and take the assessment.
Daniel Forman, MD, is Medical Director of the Cardiac Rehabilitation and Exercise Testing Laboratory at Brigham and Women's Hospital. Dr. Forman suggests that while most of focus of heart care is placed on diseases of the heart, there is an enormous opportunity to modify biology and lifestyle years before cardiopulmonary disease ever shows up. Lifestyle factors such as eating habits, exercise habits, tobacco use and sleep add up over time and lead to disease. Add biological factors like age, family history, and genetic predispositions and there are many factors that lead to disease.
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