chf team approach peter carson, md jacqueline gannuscio, msn, acnp rn washington dc
DESCRIPTION
RESEARCH Washington DC VA Medical Center Heart Failure Program OUTPATIENT CLINIC INPATIENT MANAGEMENTTRANSCRIPT
CHF Team Approach
Peter Carson, MD
Jacqueline Gannuscio, MSN, ACNP RN
Washington DC
Performance Measures Improvement: A Team Approach to Acute Hospital Management of CHFABSTRACT: Congestive Heart Failure is a prevalent problem in this country with nearly 5 million patients diagnosed. It is the most common DRG in hospitalized patients, with hospital discharges for heart failure (HF) rising 179% from 1979 to 2003. Readmission rates are as high as 50% within 6 months.
There have been positive outcomes for hospital readmission, adherence to guideline based therapy, costs, and quality of life, in outpatient HF programs. However little is known about the impact Heart Failure Teams on outcomes in the hospital.
The Washington DC Veteran’s Administration (VA) Medical Center tracks quality in the outpatient and inpatient settings by the use of Performance Measures. For heart failure, use of Angiotensin Converting Enzyme Inhibitors (ACEI) or Angiotensin Receptor Blockers (ARB) discharge instruction for diet, weight and medications are followed. In the last quarter of 2005 compliance with the last two measures met or exceeded the VA goal of 90%. Use of ACEI or ARB however was 75%.
In the fall of 2005 a team approach was initiated for management of patients hospitalized with HF, which included a Cardiologist and an Acute Care Nurse Practitioner. Each of the five medical teams were contacted daily and asked about new patients admitted with HF. Consult orders were also placed to Cardiology Heart Failure Team. These were completed by the NP within 24 hours, and diagnostic and treatment recommendations were made to the medical team. Ongoing education of medical residents and interns is an integral part of the process. There was an improvement in ACEI/ARB use during the period from 10/05 to 6/06 with 100% compliance noted at the latest review.
Use of NP’s as members of HF teams improves outcomes as measured by improvement in HF Performance Measures.
RESEARCH
Washington DC VA
Medical Center Heart
Failure Program
OUTPATIENT CLINIC
INPATIENT MANAGEMENT
JCAHO Heart Failure Measure Trends 04.01.2004-03.31.2005
33
Discharge Medications
The percentages for Aldosterone Receptor Antagonist and Subcutaneous Erythropoietin may be under-reported in the cumulative columns since these medications were added to the case report form in Q1 2004, and therefore were not available options to the total benchmark population.
LAST QUARTERn=1474
01.01.2006-03.31.2006
LAST 12 MONTHSn=13210
04.01.2005-03.31.2006
CUMULATIVEn=140841
01.01.2001-03.31.2006
ACEi or ARB (%) ACE Inhibitor (%)Angiotensin II Receptor Blocker (%)Aldosterone Receptor Antagonist (%)
67511922
67531620
6754159
Aspirin (%)Beta-blocker (%)Digoxin (%)Diuretic (%)
56762584
54742682
49643285
Lipid-Lowering (%)Nitrate (%)Subcutaneous Erythropoietin (%)Warfarin (%)
49254
30
47263
28
39291
28
52
Performance Measures for HF 10/04-8/05 VISN 5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
ACE/ARB Priorto Admit
WT InstructPrior to Admit
DC Instruc
ExpectedVISNMWVVAMHCAWASH
HF-Inpt on ACEI/ARB FY05
0
10
20
30
40
50
60
70
80
90
100
visn
22
visn
3
visn
4
visn
19
visn
23
visn
6
visn
8
visn
10
visn
21
visn
7
visn
16
visn
17
visn
18
512
Balti
mor
e
visn
15
visn
12
visn
20
visn
1
visn
11
visn
9
613
Mar
tinsb
urg
visn
5
visn
2
688
Was
hing
ton
Nat
iona
l
VAMCDC Inpatient HF ProgramComponents of Program:• Medical Teams – Primary Providers• CHF MD and NP – Medical Consultants• Nursing – Bedside Care and Education• Case Management – Discharge Planning• Dietary – Dietary Education• PT – Mobility and Functional ImprovementTools • EMR• CHF Order Set• CHF Consult• Discharge Instructions• Advanced Clinic Access
CHF Orders
Select Components of Discharge Instructions
VAMCDC ACEI/ARB 12/05-6/06
0%10%20%30%40%50%60%70%80%90%
100%
DecJanFebMarAprMayJun