Protocol 4-125 - Chronic Heart Failure Management

CMH EMS & MIH Protocols

Condition GREEN:	All Clear Zone... This is the safety zone.
Indications: None of the YELLOW or RED indications are present.
What you can do: Weigh yourself in the morning before breakfast and write your weight down. Track your daily sodium intake. Take your medications as ordered. Follow healthy eating habits: low salt and low sodium foods. Balance activity and rest periods. Monitor for swelling in your feet, ankles, legs, and stomach. Keep all medical appointments.
What your CHW might do: Review health history and PCP care plan prior to visit. Answer any questions and address any concerns you have. Review any discharge instructions from any hospital, emergency room, and/or doctor visits. Review goals from previous visit:__________ Assess adherence to care plan, including diet, exercise, medications, and keeping appointments. Review sodium intake log and weight log. Perform a 12-lead ECG. Review disease process and prevention measures with you including how and when to correctly take your medications. Education on heart disease is to be expected for every encounter specific to your diagnosis(es). Education on healthy eating and living habits is to be expected for every encounter. Specific education on diuretics as it relates to increasing weight gain and fatigue will be provided. Inspect and discuss CPAP equipment and usage. Complete a History and Physical Exam. A complete Medications Reconciliation is to be expected at every encounter. Complete a Safety Assessment. Complete a Social Assessment. Facilitate a Telehealth visit, if scheduled. Follow any verbal orders as obtained via telehealth, phone call, or electronic messaging. Schedule follow-up appointment(s) as needed that might include, but not limited to: Primary Care Provider, Addiction Recovery, Behavioral Health, Dental Care, Dietician, Home Health, Home Medical Equipment, Hospice, Pharmacy Services, Therapy Services, Public Health, Wound Care Establish goals for next visit:__________ What your CP might do: Ensure completion of applicable CHW items above. Perform venous blood draw for the following test panel: BNP BUN CBC CMP Creatinine Lipids Troponin Perform heart Ultrasound.

Condition GREEN:

All Clear Zone... This is the safety zone.

Indications:

None of the YELLOW or RED indications are present.

What you can do:

Weigh yourself in the morning before breakfast and write your weight down.
Track your daily sodium intake.
Take your medications as ordered.
Follow healthy eating habits: low salt and low sodium foods.
Balance activity and rest periods.
Monitor for swelling in your feet, ankles, legs, and stomach.
Keep all medical appointments.

What your CHW might do:

Review health history and PCP care plan prior to visit.
Answer any questions and address any concerns you have.
Review any discharge instructions from any hospital, emergency room, and/or doctor visits.
Review goals from previous visit:__________
Assess adherence to care plan, including diet, exercise, medications, and keeping appointments.
Review sodium intake log and weight log.
Perform a 12-lead ECG.
Review disease process and prevention measures with you including how and when to correctly take your medications.
Education on heart disease is to be expected for every encounter specific to your diagnosis(es).
Education on healthy eating and living habits is to be expected for every encounter.
Specific education on diuretics as it relates to increasing weight gain and fatigue will be provided.
Inspect and discuss CPAP equipment and usage.
Complete a History and Physical Exam.
A complete Medications Reconciliation is to be expected at every encounter.
Complete a Safety Assessment.
Complete a Social Assessment.
Facilitate a Telehealth visit, if scheduled.
Follow any verbal orders as obtained via telehealth, phone call, or electronic messaging.
Schedule follow-up appointment(s) as needed that might include, but not limited to: Primary Care Provider, Addiction Recovery, Behavioral Health, Dental Care, Dietician, Home Health, Home Medical Equipment, Hospice, Pharmacy Services, Therapy Services, Public Health, Wound Care
Establish goals for next visit:__________

What your CP might do:

Ensure completion of applicable CHW items above.
Perform venous blood draw for the following test panel:

BNP
BUN
CBC
CMP
Creatinine
Lipids
Troponin

Perform heart Ultrasound.

Condition YELLOW:	Warning Zone... This is the watch zone.
Indications: None of the RED indications are present. Weight gain of three (3) pounds or more in one day, Weight gain of five (5) pounds or more in one week, Increased swelling of your feet, ankles, legs, or stomach, Difficulty breathing when lying down or feel the need to sleep up in a chair, An uneasy feeling or you know something is not right, Fatigue or no energy, Dry hacking cough, Other indication set by your doctor:____________________
What you can do: You may need an adjustment to your medications. Improve your eating habits. Increase your activity level. Call your CHW or CP:____________________ Call your PCP:____________________ If outside business hours, 24-hour triage nurse screening is available by calling your PCP's number.
What your CHW might do: Ensure completion of applicable items in the GREEN zone above. What your CP might do: Ensure completion of applicable CHW items above.

Condition YELLOW:

Warning Zone... This is the watch zone.

Indications:

None of the RED indications are present.
Weight gain of three (3) pounds or more in one day,
Weight gain of five (5) pounds or more in one week,
Increased swelling of your feet, ankles, legs, or stomach,
Difficulty breathing when lying down or feel the need to sleep up in a chair,
An uneasy feeling or you know something is not right,
Fatigue or no energy,
Dry hacking cough,
Other indication set by your doctor:____________________

What you can do:

You may need an adjustment to your medications.
Improve your eating habits.
Increase your activity level.
Call your CHW or CP:____________________
Call your PCP:____________________

If outside business hours, 24-hour triage nurse screening is available by calling your PCP's number.

What your CHW might do:

Ensure completion of applicable items in the GREEN zone above.

What your CP might do:

Ensure completion of applicable CHW items above.

Condition RED:	Medical Alert Zone... This is the danger zone.
Indications: Severe difficulty breathing, Unrelieved shortness of breath while sitting still, Chest pain, Altered mental status, confusion, or inability to think clearly, Dizziness, SpO2 less than 88%, Other indication set by your doctor:____________________
What you can do: You need immediate evaluation by a medical professional. Call your CHW or CP:____________________ Call your PCP:____________________ If outside business hours, 24-hour triage nurse screening is available by calling your PCP's number. Call 9-1-1
What your CHW might do: Refer to Emergency Protocol 2-220 - Chest Pain / Suspected Cardiac Event as appropriate. Refer to Emergency Protocol 2-726 - Pulmonary Edema as appropriate. Refer to Emergency Protocol 2-770 - Respiratory Distress as appropriate. Ensure completion of applicable items in the YELLOW zone above. What your CP might do: Ensure completion of applicable CHW items above. Provide CPAP through your home device, a disposable device, or Ventilator using CPAP mode with PSV (BiPAP). Administration of Nitroglycerine 0.4 mg SL (may repeat every 5 min). If more than three doses are required, transport to an Emergency Room is needed. Administration of Albuterol 2.5 mg Neb. Assist you in the administration of your own prescribed medications.

Condition RED:

Medical Alert Zone... This is the danger zone.

Indications:

Severe difficulty breathing,
Unrelieved shortness of breath while sitting still,
Chest pain,
Altered mental status, confusion, or inability to think clearly,
Dizziness,
SpO2 less than 88%,
Other indication set by your doctor:____________________

What you can do:

You need immediate evaluation by a medical professional.
Call your CHW or CP:____________________
Call your PCP:____________________

If outside business hours, 24-hour triage nurse screening is available by calling your PCP's number.

Call 9-1-1

What your CHW might do:

Refer to Emergency Protocol 2-220 - Chest Pain / Suspected Cardiac Event as appropriate.
Refer to Emergency Protocol 2-726 - Pulmonary Edema as appropriate.
Refer to Emergency Protocol 2-770 - Respiratory Distress as appropriate.
Ensure completion of applicable items in the YELLOW zone above.

What your CP might do:

Ensure completion of applicable CHW items above.
Provide CPAP through your home device, a disposable device, or Ventilator using CPAP mode with PSV (BiPAP).
Administration of Nitroglycerine 0.4 mg SL (may repeat every 5 min). If more than three doses are required, transport to an Emergency Room is needed.
Administration of Albuterol 2.5 mg Neb.
Assist you in the administration of your own prescribed medications.

NEMSIS Protocol: 9914175 - General-Community Paramedicine / Mobile Integrated Healthcare

Citations:

Protocol 9-010 - References
Craig, 2018
McDonald, 2023
MedStar Mobile Healthcare, n.d.
TMF Quality Innovation Network, n.d.
University of Minnesota, 1986
Washtenaw/Livingston Medical Control Authority, 2019

Change Log:

Date	Link to previous version	Description of change
03/16/23		Created this section.
04/28/23	pdf	First draft using green, yellow, red format.
05/26/23	pdf	Added review of discharge instructions. Added repeat Nitro with a max of three before ER visit. Nitro repeat and three max is per Dr. Butvilas on 5/22/23.

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