Evidence Based MedicineCongestive Heart Failure Initiative

Allen Hospital, New York Presbyterian NYAM review sessionAugust 10th 2011

Evidence Based Medicine Approach

– Project began September 2009

– Learned the Basic Skills and Principles of EBM How to ask a question How to perform a relevant search Evaluation and Interpreting articles Principles of guideline evaluation and development

#1 Choose a project that counts!

– Who are your customers? Doctors: Clinical benefit Hospital: Financial benefit Patients: Improved care

#2 Involve everyone that matters!Multidisiplinary Team

ER: Dr. Leslie Miller, Dr. Peter Wyer

Hospitalist: Dr. Beth Barron, Dr. Zorica Stojanovic, Dr. Eugene Wong

Cardiology: Dr. Gerald Neuberg, Karen Stugensky, PA

Quality: Avi Fishman, Mary Ellen Hickman

Librarian: John Oliver IT: Amalga: Niloo Shobhani

Social Work: Eileen Kornfield

Nutrition: Susan Fulton Care coordination: Donna

Tingling-Solanges, Doug Morton

Nursing: Kelly Maydon, Alan Levine, Mitzy Placencia

Patient Education: Jody Scopa Goldman

Administration: Michael Fosina VP – Executive Director of Allen Hospital

# 3 Know what your problems is

Internal scan – Who are our patients? (chart review, patient calls, staff survey)

Admitted from? Discharged to? Services? Insurance? Private physician? When and if follow up scheduled? What medications d/c home on? Smoking? Diabetes? Other co-morbidities? What do the patients think about our care?

External scan – What is in the literature? Home care, Health literacy, Medications, Language barriers,

Patient education, Economic, Prediction rules, and Cardiology evaluation

#4 What will work for Allen?Knowledge Translation

Group reviewed the evidence, reviewed external guidelines and our internal reviews

Agreed that we would focus on education and the transition of care from hospital to outpatient primary care doctor

Spanish language capabilities a must

Project began 11/15

Mitzy Placencia, CHF RN– Inpatient education (Patient education handbook)– Core measures evaluation– Outpatient phone calls until seen by primary– Trouble shooting (medications, f/u visits)– Scales– Nutrition consults

CHF Education and Follow Up Pathway

Day 1 Patient is admitted through the ED • Patient admission notes are screened for appropriateness

of education.

• Patient educated on:• What is CHF• Daily weights• Sodium and Fluid Restrictions• When to call the physician

CHF Pathway Cont.

Day 2• Review sodium and fluid restrictions• Review medications with the patient and family

Day 3• Review discharge teaching:

• What to do if you notice an increase in symptoms• When to call the physician and when to come to ED.

After Discharge…

The patient is called at home 2-3 times a week for one month• Medications reconciled• Symptoms assessed• Family members and Home Attendants educated also• Troubleshooting:

• Earlier appointments, medications refilled, diuretics doses increased if necessary and more…

• Education continues!

Collaborations With Other Healthcare Professionals

CHF classes held on a weekly basis with nutrition.

Weekly meetings with VNSNY Phone calls to the field nurse of various

homecare agencies to discuss the patients’ progress and status.

#5 Measure your successes and be willing to change/evolve

Volume Impact of early follow up Issues identified with readmitted patients Impact of keeping in touch

CHF RN Coordinator monthly patients volume (11/15/10 -7/31/11 )

0

5

10

15

20

25

30

35

40

45

50

NOVEM JAN MAR MAY JULY

Number of patients

Impact of early follow up

All 198 patients had follow up appointment scheduled before discharge:

< 7 days: 111 patients (56%)

> 7 days: 87 patient (44%) 5

25

45

65

85

105

f/u<7d f/u>7d

Impact of early follow up on readmissions

8 patients (9.2%)% with f/u<7 readmitted

23 patients (20.7%) with f/u>7d readmitted

5

25

45

65

85

105

f/u<7d f/u>7d

Impact of keeping in touch

Post discharge phone call attempted on all patients seen in hospital.

Only 7 of them were unreachable 5 out of 7 were readmitted

CHF 30 Day Readmission Measures

Allen

Hospital

Q1 2010 2010 Q1 2011 2011

(Jan-May)

Readmissions

27.5% 28.36% 18.31% 20.16%

Allen Hospital: 30 day CHF Readmission Rate Jan 2009 - May 2011

0%

10%

20%

30%

40%

50%

60%

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Rea

dm

issi

on

Rat

e2009 2010 2011

Source: TSI ; Data current, as of 7/20/2011

Zorica’s lessons learned slides

We offered one size fits all (education and transition of care) approach…

and added Many different interventions were needed

for each individual patients.

Positive impact

NYP impact Allen impact

– Future projects?