The American Heart Association, the Institute of Medicine, and the US Department of Agriculture all advocate for Americans to restrict sodium intake to 2,300 mg per day [11–13]. For African Americans, those with heart disease or those over the age of 40, this restriction drops to 1,500 mg per day. However, given American’s consumption of processed products and fast food, this degree of sodium restriction is challenging for even the most dedicated individual. Since diuretics act by increasing sodium excretion in the urinary filtrate, which is followed by increased water excretion, a diet high in sodium makes diuretics essentially ineffective in controlling volume and symptoms. Patients must be taught and understand the relationship between fluid and sodium for managing volume and for controlling HF symptoms. Counseling should include repeated in-depth instruction on the components of a 2-g sodium diet, involving family members and caregivers as well. Having the patient complete a food diary over the course of several days will yield important insights into dietary habits, food preferences, and average fluid consumption. Reading food labels, low-sodium food choices when dining out, and cooking with herbs and spices to improve palatability are important aspects that should be included. Providing written materials or useful websites for low-sodium food choices and recipes is essential for success at home. As a note, salt substitutes should be used with caution, as many replace sodium chloride with potassium chloride, thus increasing the potential risk of hyperkalemia.

In advanced HF, further dietary sodium restriction may be necessary to attenuate the expansion of extracellular fluid volume and the development of edema. Although sodium restriction may mitigate the development of edema, it cannot totally prevent it because the kidneys are capable of reducing urinary sodium excretion to less than 10 mmol per day. Hyponatremia should not be treated with sodium liberalization because this hyponatremia is typically dilutional in nature and occurs in the setting of free water excess. Liberalized sodium intake or replacement should be reserved for overt cases of severe excessive diuresis and dehydration.

Within the ED and OU, simple questions about recent dietary intake may yield the cause of decompensation. Accompanying family members are also good sources of information regarding food or fluid ingestion. As discussed above, patients should understand that dietary indiscretion produces fluid retention and worsening symptoms. Thus, efforts should focus on helping patients make the association between behavior and symptoms. The challenge lies in doing this without preaching or condemning. Learning will not occur within that scenario. If a connection between a particular behavior and its negative consequences can be made, lifestyle changes are more likely to take place. However, behavioral changes do not happen overnight, and those who view the recommended changes as personal choices, rather than as edicts imposed by others, are more likely to make permanent lifestyle modifications [2].

Recognizing obvious sources of sodium, such as a saltshaker or potato chips, is evident for most patients, but in a typical diet, they constitute less than 25 % of total sodium intake. Hidden sources of sodium play a greater role in dietary intake and yet are often unrecognized. Good HF clinicians are also good detectives. Common high-sodium content items include, but are not limited to, canned soups and vegetables, pickles, cheeses, softened water, tomato juice, antacids, and processed foods. As discussed above, a food diary provides important information on food choices and eating patterns. Having the patient start this diary after treatment in the emergency department affords the clinician next evaluating the patient much-needed information and the ability to discuss alternative lower-sodium choices. The ED and OU should be stocked with printed materials for patients and families to use at home.

Pharmacologic interventions are vital to managing symptoms and halting disease progression in HF. Yet, medications for heart failure are both complex in their administration and costly. Polypharmacy, or the need for multiple medications, is a normal consequence of an evidence-based approach to managing HF because beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin receptor blockers, aldosterone inhibitors, electrolyte supplements, and diuretics must all be taken at different times throughout the day. New medications for HF, such as ivabradine or sacubitril/valsartan, or medications for comorbidities, infections, or other needs are prescribed, have dose changes, or are discontinued. No wonder patients become confused and fail to take as directed.

Potential barriers to medication adherence should be identified and addressed. Besides financial barriers, other frequently missed obstacles include real or perceived side effects, depression, forgetfulness, and understanding the importance of and need for the medication [7, 8]. To improve self-care and adherence, ongoing discussions must occur between clinicians and patients to reach understanding and agreement on the necessity for medications and the appropriate regimen [8]. Rather than mandated or imposed views, this discussion may require some compromise from both parties, as a patient may agree to take more medications than initially desired or a clinician acknowledges the patient may be taking less than is ideal. What is most important is that healthcare providers know all medications being taken.

Medication reconciliation is the process of comparing medication orders to all of the medications the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. More than half of patients have at least one medication discrepancy on admission to a hospital [14]. In addition, there is an increased risk for discrepancy at every transition point: from home to ED, ED to admission, one unit to another, and inpatient to discharge. Recognizing that medication errors put patients at risk and are largely preventable, the Joint Commission named medication reconciliation as the 2005 National Patient Safety Goal #8. The first step in medication reconciliation is to obtain the most accurate list of current medications prior to giving any medications in the ED (except in emergency or urgent scenarios). This includes prescription and over-the-counter medications, vitamins, and supplements, noting the dose, route, frequency, indication, and time of the last dose for each. Each facility likely has a specific form and process for documenting medication history and adherence. Besides the patient and family, the patient’s pharmacy and previous medical records may be reliable sources of information. Patients should be instructed to bring all of their medications whenever seeking or receiving healthcare.

To assist with adherence, a variety of aids are available and may be helpful to some. These aids include pill boxes, medication trackers, timers, or interactive websites, to name few. For those with financial constraints, most major pharmaceutical companies offer assistance programs for individuals unable to afford medications. Many require documentation of medical necessity from the prescriber, and patients may need to submit documentation of financial need as well. Although this process is unlikely to be initiated in the ED, it is important to recognize resource options and to make the necessary referrals. Access to social worker or case management staff can be quite valuable in addressing these concerns.