HEART FAILURE

TEAM MEMBERSHIP

CARDIOLOGY, CARDIOVASCULAR SURGERY, MEDICINE, NURSING, QRM, CCE, MEDICAL RECORDS

PROJECT COORDINATORS

CARMEN BARC, RN, BSN

CAROL KEELER, RN, MS

Heart failure accounts for more hospital admissions than any other Medicare diagnosis. Research shows that the following care processes decrease morbidity and mortality rates for heart failure patients:

Left ventricular systolic function assessment

ACEI or ARB prescribed for LVSD (EF <40% or description of moderate/severe dysfunction)

Smoking cessation counseling

Written discharge instructions regarding activity, diet, follow-up, medications, symptoms worsening, and weight management

Our goal is to achieve 100% compliance to these measures.

Source: www.jcaho.org

OPPORTUNITY STATEMENT

Concurrent patient care and retrospective chart review indicated an opportunity for improvement in process and outcome for each of the measures.

PLAN

Implement a Heart Failure Core Measures program in accordance with JCAHO/CMS guidelines

DO

•HF Task Force formed

•Nursing clinical ladder opportunity offered for data collection and entry

•Pilot study of core measure performance for DRG 127

ACT

•Physician and nursing staff education

•Develop HF-specific documentation forms

•Decrease data variability

STUDY

•Current processes not adequately fulfilling project requirements

•Lack of house-wide awareness/understanding of HF Core Measures

•Data variability identified

Cycle 1Cycle 1

PL A N

D

O

S TU

DY

A

C

T

PLAN

DO

STUDY

ACT

Cycle 2Cycle 2PLAN•Capture HF patient population using ICD-9 codes rather than DRG coding

•Dedicated FTEs for the Core Measures initiative

•Revise HF Discharge Progress Note(DPN) addendum

•Physician and nursing staff education

DO•100% chart review based on ICD-9 diagnosis codes

•Nursing Quality Specialist given responsibility for data collection and entry as well as education

•DPN addendum revision to include documentation of ARB as potential contraindication to ACE inhibitor

•Multidisciplinary education by in-services and point of service posters/ information

STUDY•Improved documentation of D/C instructions

•LV assessment documentation peaked to a level of excellence

•Decreased data variability

•Continuity of required documentation house-wide needs improvement

ACT•Attend nurse managers meeting to discuss National Hospital Quality Measures

•Place HF packets – including standard order sets, discharge instructions, and discharge progress note addendum – in the ED, EP lab, and all patient care areas that treat the HF population

PL A N

D

O

S TU

DY

A

C

T

PLAN

DO

STUDY

ACT

Cycle 3Cycle 3PLAN•Focus on unit and nurse specific performance

DO•Analyze and provide unit and nurse specific performance data to managers

•Provide overall performance data to the HF task force

STUDY•High volume cardiac units tend to perform well; however, there is still an opportunity for improvement

•Surgical and non-cardiac units need further education regarding the HF measures

•Staff nurses perform better than agency nurses

ACT•Surgical and non-cardiac unit-specific education

•Agency and registry nurse education

•Involve cardiac rehabilitation nurses, heart transplant case managers and nurse practitioners, as well as cardiovascular case managers and nurse practitioners

PL A N

D

O

S TU

DY

A

C

T

PLAN

DO

STUDY

ACT

Per

cen

tHeart Failure Patients Receiving Left Ventricular Systolic Function Assessment

* Preliminary data for quality improvement purposes only

Month

Jan-0

4 (n

=55)

Feb-0

4 (n

=56)

Mar

-04

(n=3

5)

Apr-04

(n=5

8)

May

-04

(n=6

0)

Jun-0

4 (n

=47)

Jul-0

4 (n

=58)

Aug-04

(n=5

5)

Sep-0

4 (n

=35)

Oct-0

4 (n

=57)

Nov-04

(n=4

9)

Dec-0

4 (n

=50)

Jan-0

5 (n

=69)

Feb-0

5 (n

=53)

Mar

-05

(n=6

9)

Apr-05

(n=5

7)

May

-05

(n=7

3)

Jun-0

5 (n

=52)

Jul-0

5 (n

=52)

Aug-05

(n=5

8)

Sep-0

5 (n

=62)

*Oct

-05

(n=5

6)

*Nov-

05 (n

=71)

*Dec

-05

(n=7

6)

*Jan

-06

(n=4

8)

*Feb

-06

(n=2

6)90

92

94

96

98

100

102

104

106

UCL = 103.54

Mean = 98%

LCL = 92.98

Pe

rce

nt

National Hospital Quality Measures

* Preliminary data for quality improvement purposes onlyMonth

Jan-0

4 (n

=43)

Feb-0

4 (n

=46)

Mar

-04

(n=2

8)

Apr-04

(n=5

2)

May

-04

(n=5

7)

Jun-0

4 (n

=41)

Jul-0

4 (n

=50)

Aug-04

(n=5

1)

Sep-0

4 (n

=33)

Oct-0

4 (n

=51)

Nov-04

(n=4

3)

Dec-0

4 (n

=44)

Jan-0

5 (n

=61)

Feb-0

5 (n

=50)

Mar

-05

(n=5

9)

Apr-05

(n=5

2)

May

-05

(n=6

6)

Jun-0

5 (n

=46)

Jul-0

5 (n

=47)

Aug-05

(n=5

2)

Sep-0

5 (n

=54)

*Oct

-05

(n=4

9)

*Nov-

05 (n

=65)

*Dec

-05

(n=7

0)

*Jan

-06

(n=4

4)

*Feb

-06

(n=2

6)

40

50

60

70

80

90

UCL = 83.62

Mean = 62.97

LCL = 42.32

Distributed HF Packets to ED

and units that treat HF population

Heart Failure Patients Receiving Complete Discharge Instructions Prior to Discharge

* Preliminary data for quality improvement purposes only

Month

Jan-0

4 (n

=43)

Feb-0

4 (n

=46)

Mar

-04

(n=2

8)

Apr-04

(n=5

2)

May

-04

(n=5

7)

Jun-0

4 (n

=41)

Jul-0

4 (n

=50)

Aug-04

(n=5

1)

Sep-0

4 (n

=33)

Oct-0

4 (n

=51)

Nov-04

(n=4

3)

Dec-0

4 (n

=44)

Jan-0

5 (n

=61)

Feb-0

5 (n

=50)

Mar

-05

(n=5

9)

Apr-05

(n=5

2)

May

-05

(n=6

6)

Jun-0

5 (n

=46)

Jul-0

5 (n

=47)

Aug-05

(n=5

2)

Sep-0

5 (n

=54)

*Oct

-05

(n=4

9)

*Nov-

05 (n

=65)

*Dec

-05

(n=7

0)

*Jan

-06

(n=4

4)

*Feb

-06

(n=2

6)

40

50

60

70

80

90

UCL = 83.62

Mean = 63%

LCL = 42.32

Per

cen

t

Heart Failure Patients With Left Ventricular Systolic Dysfunction ReceivingACE Inhibitor or ARB Prescription at Discharge

* Preliminary data for quality improvement purposes only

Month

Jan-0

4 (n

=25)

Feb-0

4 (n

=24)

Mar

-04

(n=1

4)

Apr-04

(n=2

5)

May

-04

(n=2

5)

Jun-0

4 (n

=20)

Jul-0

4 (n

=24)

Aug-04

(n=2

2)

Sep-0

4 (n

=15)

Oct-0

4 (n

=26)

Nov-04

(n=2

4)

Dec-0

4 (n

=21)

Jan-0

5 (n

=40)

Feb-0

5 (n

=35)

Mar

-05

(n=3

4)

Apr-05

(n=3

0)

May

-05

(n=4

3)

Jun-0

5 (n

=31)

Jul-0

5 (n

=27)

Aug-05

(n=3

2)

Sep-0

5 (n

=31)

*Oct

-05

(n=3

0)

*Nov-

05 (n

=47)

*Dec

-05

(n=4

5)

*Jan

-06

(n=2

6)

*Feb

-06

(n=1

3)

60

70

80

90

100

110

UCL = 104.88

Mean = 84%

LCL = 63.57

Per

cen

t

Per

cen

tSmokers Receiving Smoking Cessation Counseling for Heart Failure Patients

* Preliminary data for quality improvement purposes only

Month

Jan-0

4 (n

=7)

Feb-0

4 (n

=7)

Mar

-04

(n=6

)

Apr-04

(n=9

)

May

-04

(n=1

1)

Jun-0

4 (n

=4)

Jul-0

4 (n

=10)

Aug-04

(n=3

)

Sep-0

4 (n

=4)

Oct-0

4 (n

=4)

Nov-04

(n=7

)

Dec-0

4 (n

=10)

Jan-0

5 (n

=14)

Feb-0

5 (n

=11)

Mar

-05

(n=1

0)

Apr-05

(n=8

)

May

-05

(n=1

8)

Jun-0

5 (n

=8)

Jul-0

5 (n

=9)

Aug-05

(n=9

)

Sep-0

5 (n

=15)

*Oct

-05

(n=1

5)

*Nov-

05 (n

=15)

*Dec

-05

(n=2

1)

*Jan

-06

(n=8

)

*Feb

-06

(n=6

)0

20

40

60

80

100

120

140

UCL = 117.84

Mean = 77%

LCL = 36.38

Per

cen

tHeart Failure Patients With Left Ventricular Systolic Dysfunction Receiving

ACE Inhibitor or ARB Prescription at Discharge

* Preliminary data for quality improvement purposes only

Month

LUHS ACE Inhibitor or ARB for LVSD RateUHC Academic Hospitals ACE Inhibitor or ARB for LVSD RateNational ACE Inhibitor or ARB for LVSD Rate

Jan-0

4

Feb-0

4

Mar

-04

Apr-04

May

-04

Jun-0

4

Jul-0

4

Aug-04

Sep-0

4

Oct-0

4

Nov-04

Dec-0

4

Jan-0

5

Feb-0

5

Mar

-05

Apr-05

May

-05

Jun-0

5

Jul-0

5

Aug-05

Sep-0

5

*Oct

-05

*Nov-

05

*Dec

-05

*Jan

-06

*Feb

-06

70

80

90

100

110

120

Per

cen

tHeart Failure Patients Receiving Complete Discharge Instructions Prior to Discharge

* Preliminary data for quality improvement purposes only

Month

LUHS Discharge Instruction RateUHC Academic Hospitals Discharge Instruction RateNational Discharge Instruction Rate

Jan-0

4

Feb-0

4

Mar

-04

Apr-04

May

-04

Jun-0

4

Jul-0

4

Aug-04

Sep-0

4

Oct-0

4

Nov-04

Dec-0

4

Jan-0

5

Feb-0

5

Mar

-05

Apr-05

May

-05

Jun-0

5

Jul-0

5

Aug-05

Sep-0

5

*Oct

-05

*Nov-

05

*Dec

-05

*Jan

-06

*Feb

-06

40

50

60

70

80

90

100

110

120

Per

cen

tHeart Failure Patients Receiving Left Ventricular Systolic Function Assessment

* Preliminary data for quality improvement purposes only

Month

LUHS Left Ventricular Function RateUHC Academic Hospitals Left Ventricular Function RateNational Left Ventricular Function Rate

Jan-0

4

Feb-0

4

Mar

-04

Apr-04

May

-04

Jun-0

4

Jul-0

4

Aug-04

Sep-0

4

Oct-0

4

Nov-04

Dec-0

4

Jan-0

5

Feb-0

5

Mar

-05

Apr-05

May

-05

Jun-0

5

Jul-0

5

Aug-05

Sep-0

5

*Oct

-05

*Nov-

05

*Dec

-05

*Jan

-06

*Feb

-06

85

90

95

100

105

110

115

120

Per

cen

tSmokers Receiving Smoking Cessation Counseling for Heart Failure Patients

* Preliminary data for quality improvement purposes only

Month

LUHS Smoking Cessation Advice RateUHC Academic Hospitals Smoking Cessation Advice RateNational Smoking Cessation Advice Rate

Jan-0

4

Feb-0

4

Mar

-04

Apr-04

May

-04

Jun-0

4

Jul-0

4

Aug-04

Sep-0

4

Oct-0

4

Nov-04

Dec-0

4

Jan-0

5

Feb-0

5

Mar

-05

Apr-05

May

-05

Jun-0

5

Jul-0

5

Aug-05

Sep-0

5

*Oct

-05

*Nov-

05

*Dec

-05

*Jan

-06

*Feb

-06

50

60

70

80

90

100

110

120

NEXT STEPS

Involve cardiac rehabilitation nurses as well as cardiovascular NPs in the NHQM initiatives

Analysis of physician specific performance

Computerize discharge processes

Evaluate process/outcome improvement resulting from interventions

Continue public reporting of performance measures