CORRESPONDENCE: LETTERS TO THE EDITOR
Bridging the Resource Gap in Heart Failure Expertise and Management: The Underacknowledged Role of Nurse Specialists
Kismet D. Rasmusson, FNP*,
Sally J. Brush, FNP,
Jill A. Hall, FNP,
Jill C. Vesty, FNP,
Abdallah G. Kfoury, MD, FACC and
Dale G. Renlund, MD, FACC
* Heart Failure Prevention and Treatment Program, Intermountain Health Care, LDS Hospital, Salt Lake City, UT 84143 (Email: ldkrasmu{at}ihc.com).
Recent studies in the Journal have raised concerns regarding the limited availability of heart failure (HF) specialists. Because HF care now incorporates increasingly complicated strategies and technologies, and because the number of HF patients is burgeoning, capable and specialized providers are in greater demand. The backbone of management must not be forgotten, however, and, as Konstam (1) suggests, "highly specialized clinicians" will clearly be needed to master the evaluation of the HF patient and the timing of HF interventions. The foundation of HF care rests upon the cognitive aspects: identifying and diagnosing the problem, using evidence-based medications, maintaining appropriate intravascular volume status, educating patients about the disease process, and considering device-related and end-of-life issues. Those termed "plumbers" and "electricians" by Naccarelli (2) should not replace, but augment, those who provide the cognitive aspects of HF care.
However, economic remuneration and exciting advances in procedural therapies have led many cardiologists away from the core of HF management, resulting in a shortage of HF providers. Less attention has been paid to the comprehensive strategies provided by specially trained nurses who have shown improved HF outcomes in the past and should not be overlooked as other solutions are posed. When studied in the context of multidisciplinary teams, often led by cardiologists, nurse specialists have been shown to contribute significantly to improving outcomes. The review by McAlister et al. (3) of 29 trials has identified that one of the three "crucial" elements in a successful program is the use of specially trained HF nurses. What role do nurse specialists have in HF management? They are able to monitor patients’ intravascular volume status, titrate HF medications, triage and often avert admissions with appropriate telemanagement, and educate patients and families. Additionally, nurse specialists assist with complex levels of care when faced with end-stage strategies of transplant, end-of-life issues, or mechanical support.
Finally, the growing global burden of HF necessitates the investigation into alternative methods of providing coordinated, integrated, and focused care for patients. Though a clear need exists for subspecialized care of HF patients so that all appropriate options can be provided, the role that nurse specialists play in managing patients across the spectrum should be fully acknowledged. Nurse specialists should be part of the solution to the growing HF provider shortage, as multidisciplinary HF team members, in a position that enhances and complements the vital role of "cognitive, electrician, or plumber" HF cardiologists.
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References
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- Konstam M. Heart failure training J Am Coll Cardiol 2004;44:1361-1362.[Abstract/Free Full Text]
- Naccarelli GV. Does it make sense to train plumbers as electricians? J Am Coll Cardiol 2004;44:1358-1360.[Abstract/Free Full Text]
- McAlister FA, Steward S, Ferrua S, McMurray JJJ. Multidisciplinary strategies for the management of heart failure patients at high risk for admission. A systematic review of randomized trials J Am Coll Cardiol 2004;44:810-819.[Abstract/Free Full Text]
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