HeartBeats Episode 23: Lee Health’s Heart Care Transition Clinic & Rapid Diuresis

Host:

Hi, I'm Cathy Murtagh-Schaffer and I'm your host for this episode of HeartBeats. This podcast is brought to you by Shipley Cardiothoracic Center, an educational series dedicated to providing our patients and the community with information and education about our cardiothoracic surgery program, Lee Health and matters affecting your health. Today, I have the privilege of talking with a friend and colleague, Melissa Gilliam, a fellow Physician Assistant and Supervisor of the Heart Care Transition Clinic here at HealthPark Medical Center. For those of you who are not familiar with this clinic, it provides a valuable resource to some of our more fragile patients who suffer with heart failure and atrial fibrillation. Without this clinic, many more patients would end up in the emergency room with difficulty breathing. We'll talk a little bit more about that shortly. So anyway, welcome Melissa, glad you joined us. I remember when I first started working at HealthPark, you were one of the first people I met and you often would help me get my bearings as I wandered around trying to find things. Maybe we can begin by you telling us a little bit about your career and how you became an integral part of the heart failure team.

Melissa Gilliam:

So I've been a Physician Assistant for about 16 years now and working with Heart and Vascular Institute, which is part of Lee Health in cardiology for the last six years. Over the past four years, we've really focused on the heart failure side and we've done a follow-up clinic, which is this Heart Care Transition Clinic, as well as a treatment clinic called Rapid Diuresis.

Host:

So to give our listeners a little background, as we've mentioned before on this podcast, the heart has four chambers and each chamber has a valve that allows one-way blood flow. In order to move blood through those chambers, the heart has to squeeze or pump. That squeeze is often called an ejection fraction. It describes how much of the blood that is delivered to the heart is squeezed out into the system when that squeezes diminished or the valves aren't working correctly, patients end up with heart failure. Would you agree with that description?

Melissa Gilliam:

Yes, Cathy, the heart can either be too weak or too stiff or be a combination of this that can end up causing heart failure.

Host:

Can you describe some of the symptoms that patients experience with heart failure?

Melissa Gilliam:

Sure, one of the most common is shortness of breath and usually what precedes that is weight gain also can have abdominal bloating, poor appetite, and swelling of the legs.

Host:

That's why we so often ask our patients to weigh themselves daily and to avoid salt. It's all about fluid accumulation that builds up in the system and eventually causes this shortness of breath and can cause people to go into extreme respiratory distress.

Melissa Gilliam:

Absolutely.

Host:

Melissa, what do you see as the most frequent cause for the sudden onset of symptoms?

Melissa Gilliam:

So this can vary depending on the type of heart failure or the reason why they have heart failure. But one of the most common things we see is that they eat too much salt. They may not even add salt from a shaker, but the food already has it in it and they're not realizing that. Other things is, you know, if they don't take their medications like they're supposed to, because they don't want to be on a road trip and using the bathroom from a diuretic or water pill. Other things is if their blood pressure's too high and it's not controlled, if they develop some blockage or coronary artery disease that can exacerbate heart failure. Even, the heart beating too fast or too irregular, which will be tachycardia or arrhythmias. If the heart valve was not functioning, either too stiff or too floppy, we call it basically. And it gets worse that can also exacerbate symptoms and then too much alcohol can also contribute. So there's quite a few things, but you know, really dietary wise we try to focus on that.

Host:

And some of those things not only affect the volume as we call it, but also the rhythm of the heart, for instance, alcohol can really exacerbate atrial fibrillation and then all of a sudden you've got this very fast heart rate going on and everything starts to backload and here you are having these types of symptoms. The other thing I think that you mentioned that I think has a lot of importance is the salt process that goes into food. We see patients who adamantly tell us I'm not using salt, I'm not using salt, but they'd been to McDonald's, they've been to Burger King, they've been to Chick-fil-A and all of those foods have tremendous amounts of salt in them and canned foods in particular have a lot of sodium.

Melissa Gilliam:

Exactly, I was going to say, even in the stores, they don't have to eat out. They don't realize it because they're not adding it from a shaker, but it's already either packed in it, preserved in it, you know, lunch meats, et cetera, all those things have high salt or sodium content.

Host:

It's a bit difficult for, especially for some of our older patients to change the way they think about food and what they're eating, and sometimes it's a matter of economics. They just can't afford to buy fresh food or organic or however you want to put it, but it does play a big role in the way their health is affected.

Can you talk a little bit about how the heart care transition clinic works?

Melissa Gilliam:

The Heart Care Transition Clinic it's actually located inside of HealthPark Medical Center but it is an outpatient clinic. We are also going to look to expand to the Cape Coral area because of the need out in that area as well. And basically we see patients within three to five days after they've been admitted to the hospital for heart failure. The advanced providers that work in this clinic review their hospitalization, they review their medications that they were given, review the labs that they had done, testing that they had done, and the notes. The key piece is discharge medication review because they might've had their medications changed throughout the hospitalization. We see them within that three to five day window, because they need to understand what was changed, what they shouldn't be taking any longer, what they should be filling. And then the providers, you know, they talked to the patients, they ask them questions, they do a physical exam, paying attention to listening to their heart, listening to their lungs, checking for swelling. And then they do a great deal of education. As we've already mentioned, it plays a huge role with the dietary piece and then also weighing themselves. We teach our patients to weigh themselves every day and record it in a log and we have this book that we give them to record it in and you know, we educate them. If you're gaining two to three pounds overnight, you know, you need to stop and think what's going on. How am I doing? How am I feeling? In some patients we might actually educate them to do things a little differently on that at that point. In other patients we might say, wait another day and see if you lost that two or three pounds, or is it going up again? But really once you reach that threshold five pounds in a week, and sometimes sooner, you really need to call your provider.

We educate them to call their primary cardiology team to get some guidance. Is it just increasing my diuretics, which are the water pills? Is it, I need something different for my blood pressure, my heart rate, it depends. And then from there, we also at the end of our visit make sure they go back to their primary cardiologist. So we see them in this kind of interim three to five days, and then we make sure that they go and see their primary cardiology team in about four weeks after they see us sometimes a little less, sometimes a little more depending on if we have to do some major adjustments on their visit.

Host:

So you guys are the specialty clinic for heart failure, but basically everybody should be following with their cardiologist. The point you bring up about medication, we see the same issue for our surgical patients as well. They go home with a change in medication, they don't understand that they've got this change. The medicines they were taking are still in the medicine cabinet. So now what do I do with this one? This one says twice a day, this one says three times a day, or is this the same as this one? Because the names are different, but, and there's so much confusion around medications.

Melissa Gilliam:

And honestly, you know, in that first three to five day window of being discharged, one of the reasons why people end up getting, going back to the hospital is, you know, "sorry, I didn't take the right thing, I didn't know, wasn't sure what I was supposed to take". The discharge paperwork is large and it's sometimes they need a little extra help reviewing things.

Host:

Yeah, the discharge paperwork is cumbersome at times, and I'm not sure that people even attempt to try to read through it. They figure, "oh, they told me all this already. I don't need to read this". I think one of the more common things that I've seen in all heart failure patients is this anxiety that comes on when you're not able to breathe properly. I have seen the same anxiety in patients with COPD and asthma patients. Our brain goes into panic mode when it thinks we're not getting enough oxygen. So Melissa, what can patients do to reduce some of that anxiety? Because it plays a huge role in managing their symptoms. In fact, I would say it's one of the big reasons people show up in the emergency room, their anxiety overwhelms them, and then they can't breathe.

Melissa Gilliam:

Exactly, so this kind of manifestation of not being able to breathe and getting anxious, one of the things that we teach our patients is how to help control their breathing is we call it pursed lip breathing. It's very simple and basically you relax your shoulders, your neck, and you take in the deep breath in through your nose, they say as if you're smelling the roses and then you purse your lips as if you're about to whistle and you blow out, like you're blowing out a candle that helps control the rate of the breathing and therefore controls their anxiety level. And obviously there are other things that, you know, we talk about with our patients to help with their anxiety, you know, having a good support system and all those sorts of things help. But in that moment of panic, I think the pursed lip breathing is kind of the way.

Host:

That's actually an interesting concept because I know that that's one of the tricks that they teach PTSD patients is how to control that anxiety. And it's about controlling the vagal response that they get to their anxiety. Very interesting.

One of the great arms of the heart failure clinic is the Rapid Diuresis Melissa, tell us how this clinic works to manage symptoms.

Melissa Giliam:

Sure, another piece that we have in our Heart and Vascular Institute part of Lee Health here is not just the follow-up piece of the Heart Care Transition Clinic, but it's actually, this other piece is called Rapid Diuresis which is actually more of managing and treating patients. This is for patients who already have known heart failure and they have gotten to that point where they're not in severe distress, meaning the emergency room, but they just have this fluid accumulation and it's just not working with the pills. So whether their provider had increased their oral medications and it's just not, it's not coming off, they're still gaining weight, they're still feeling symptoms. That's kind of the sweet spot where this clinic fits in. The patients are in the acute care facility in one of the campuses, and also we do this at the Complex Care Center in downtown Lee, but they're considered outpatient and they get an IV place, they get blood drawn. So we're basically checking their kidney function, their electrolytes and if everything's acceptable, we give them the IV medications that are like the water pills they take basically and it helps get rid of the fluid, helps them diaries. They are there for majority of the day because we're monitoring their fluid output, you know, how much they're drinking, how much they're urinating. As long as they're stable enough, they go home that same day. Some people have to come back in a couple of days for another treatment, if they've had too much accumulation of fluid prior to seeing us. And some people just go home after that one time of the diuretics, and then we make sure they get follow-up after that treatment. So whether it's the Heart Care Transition Clinic piece or it's their primary cardiologist, depending on availability, we want them to be seen within a couple of days as well, three to five days again is the target in order to reevaluate, do they need more rapid diuresis, are they stable, do we need to adjust any medications, et cetera?

Host:

One of the big problems with heart failure is that whole dynamic that involves the kidneys itself and the kidneys get damaged in heart failure. It's just this whole systemic response, but diuresis patients with kidney failure is tricky business.

Melissa Gilliam:

Yeah, we actually do collaborate with nephrology. So the nephrologist in town, they even refer some patients to us that a lot of patients see nephrology and cardiology with heart failure and we collaborate with them. Whether we involve them with the decision-making and what to give, or we involve them in the outpatient follow-up piece. They help us, and in some cases actually when we give the IV diuretics, their kidney function or creatinine and will actually improve. It's a fine line and it's a fine balance and it's basically us working through what we need to do on an individual basis for each patient.

Host:

Yeah. That's why I call it a tricky business.

Melissa Gilliam:

It's very tricky, and you know, this clinic, this rapid diuresis piece, all the local cardiologists in our area are aware of this availability. And if patients feel that they might benefit from something like this, I just encourage them to talk to their primary cardiology team and they can help get the information that they need to possibly get this sort of treatment.

Host:

So in order to get into clinic, they need to be referred by their primary cardiologists?

Melissa Gilliam:

Yeah, Primary care physicians can also refer, but I usually tell patients the first point of contact should really be your primary cardiologists because they might just adjust their pills first, and do small adjustments or go to the office. But also primary care physicians are also aware of this process and program as well.

Host:

Wow, I bet this plays a huge role in preventing readmissions. Patients can be seen in the clinic, get diaries and can go home from there. It used to be, these folks would sit forever in the emergency room, get admitted, and then spend two to three days in the hospital. What a great service for patients

Melissa Gilliam:

It's made a difference in our patients.

Hotst:

I bet it has. I bet it has. And the fact that you all are thinking about expanding out to Cape Coral, that's even a better enlargement for this service, definitely.

Melissa, thank you so much for being here today. You and your team are caring for some of our sickest patients and doing such an incredible job of trying to keep them out of the hospital and providing them with a quality of life. Is there anything else you want to add before we go?

Mellisa Gilliam:

You know, I'd just like to say thank you first of all and also, just a really a reminder to our patients who have heart failure, take your medications like you're supposed to, follow up when you're supposed to, eat a low sodium diet, don't have too little or too much fluid and really talk to your medical team on specifics for all of this, because it might be a little different for everybody.

Host:

Well until next time I'm Cathy Murtagh-Schaffer and this has been HeartBeats Shipley Cardiothoracic Centers podcast dedicated to bringing research innovation and education to our patients and the community until next time.