Expanding nurse practitioner scope of practice to improve heart failure medication optimization in an outpatient cardiac clinic

Over 600 000 Canadians are currently living with heart failure (HF), it is a progressive condition, characterized by high mortality rates, and frequent hospitalizations and readmissions (1). Despite being three years after the rise of coronavirus disease (COVID-19), the pandemic continues to cast its shadow on the healthcare system carrying unintended negative consequences on patient outcomes. A study conducted in Toronto demonstrated that early in pandemic there were fewer patient presentations to the emergency department with acute decompensated HF, however despite these trends there were higher HF in-hospital mortality rates (2). It is further suggested that likely the changes in patient care in response to public measures, as well as fear and inability to access care in a timely manner, may have led to additional heart failure deaths. (2). This signifies the importance of improving access to and the provision of timely evidence-based care and patient education in the outpatient settings. 

Our organization, Partners in Advanced Cardiac Evaluation (PACE Cardiology) is an outpatient cardiac clinic focused on research, diagnostics and delivery of evidence-based cardiac care. The organization is affiliated with major cardiac centers which allows a seamless transition between inpatient and outpatient worlds. Preliminary search conducted by our team identified a substantial number of patients with HFrEF who may be eligible for the medication optimization in the clinic (4). This signifies the clear need for an organized approach which would offer comprehensive care in evaluation, initiation and uptitration of guideline directed medical therapy (GDMT) which is considered to be the gold standard in HF management (2, 3).   

Early initiation of therapy as well as timely follow-up care after hospitalization is essential for overall improvement of outcomes, and can be achieved through regular medication optimization clinics (5). Nurse Practitioners with specialized knowledge and expertise in HF management are essential for the provision of comprehensive care for these patients.  As a team, we are launching a Nurse Practitioner (NP)-led HF medication optimization clinic, geared at initiation and optimization of GDMT. From this stemmed my need and motivation to further expand my competence and expertise in heart failure management, in order to actively participate in the medication optimization initiative. 

Through this fellowship, my goal was to develop and grow my clinical knowledge and expertise of the HF management, thereby to improve continuity of care and patient outcomes in an outpatient setting. After 4 months of intensive learning and clinical practice, not only was I able to achieve my goal, but also build a solid foundation for ongoing growth and learning in this area. 

My clinical experience took place at Southlake Regional Health Center, between three practice settings, including initial consults taking place in emergency department (ED), followed by an in-patient unit and an outpatient Heart Function Clinic. Choosing the hospital setting for my learning environment provided the opportunity to monitor and evaluate patient responses to therapy in real time, which was instrumental to solidifying my knowledge and understanding of the HF patient population, both in stable and acute decompensated states, as well as the role of medical management. 

I was able to enhance my knowledge base and skills in recognizing HF clinical manifestations and symptom presentation, including interpreting diagnostic tests and their significance to making diagnosis. I was able to fine tune and enhance my clinical assessment skills pertaining to cardiovascular assessments, particularly fluid volume status assessment. Specific focus was attributed to gaining an in-depth understanding of the GDMT, initiation of the therapy, up-titration process, and assessment of appropriateness of interventions. Moreover, I was able to gain a better understanding of the role of diuretic therapy for patients presenting with both acute decompensated heart failure and stable symptoms, as well as gain experience in initiating, monitoring and adjusting the dosage. Collaborating with and learning from the experts in HF management gave me an opportunity to challenge myself in a supported environment and apply the newfound knowledge of HF management when devising the care plans for patients. I was able to practice and further build my skill set in providing client education in HF disease progression, symptom recognition, medication compliance, and to support patients in gaining back their independence. This fellowship enriched my knowledge, confidence, clinical judgement and skills and prepared me to deliver comprehensive care and manage complex HF patients in the outpatient environment.