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IHI Expedition:

Effective Implementation of Heart Failure Core

Processes

Peg Bradke, RN, MA, Faculty

Christine McMullan, MPA, Director

January 5, 2012

These presenters have nothing to disclose

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Today’s Agenda • Homework Discussion

─ Peg Bradke/Chris McMullan

• Prescribing of anticoagulant

at discharge for chronic atrial

fibrillation/A New Perspective:

The St. Luke’s Story ─ Sue Halter, RN, St. Luke’s Hospital

• Questions and Answers

• Homework for next session

─ Peg Bradke/Chris McMullan

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Christine McMullan

Chris McMullan, MPA, is the Director of

Continuous Quality Improvement at Stony Brook

University Medical Center. She served as an

adjunct faculty member at the Harriman Business

School and School of Professional Development

at Stony Brook University. She was Lead Faculty

on the IHI Early Warning Systems: The Next Level

of Rapid Response Expedition and a Faculty

member on the IHI Sepsis Detection and Initial

Management Expedition. She was a co-faculty

member of the Hospital Association of New York

State's 2007 learning collaborative to prevent

ventilator associated pneumonia. Ms. McMullan

has held a variety of managerial positions in

quality improvement and human resources.

Peg Bradke, RN, MA

Peg M. Bradke, RN, MA, Director of Heart Care

Services, St. Luke's Hospital, coordinates services for

two intensive care units, two step-down telemetry

units, the Cardiac Catheter Lab, Electrophysiology

Lab, Diagnostic Cardiology, Interventional/Vascular

Lab, and Cardiopulmonary Rehabilitation. In her 25-

year career, she has had various administrative roles

in critical care areas. Ms. Bradke works with the

Institute for Healthcare Improvement on the

Transforming Care at the Bedside initiative and

Transitions Home work. She is President-Elect of the

Iowa Organization of Nurse Leaders.

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Follow to some further references from the last call. A few tools have been recommended recently on the H2H listserv www.H2HQuality.org HF Videos We are pleased to announce Heart Talk, a set of heart failure teaching videos and other education materials now available free of charge over the web. Qualidigm, a Connecticut Quality Improvement Organization, received funding from CMS for this project to enhance the care of heart failure nationally. Three video series are available for viewing: one for nurses, one for nursing assistants, and one for patients. The videos include instruction on diastolic vs. systolic heart failure, medical and surgical therapy, dietary counseling, teach back, palliative care, and many other topics. You can also find downloadable educational materials for patients such as weight charts and zones. Please follow the link below to learn more. http://www.qualidigm.org/CommunitiesOfCare/HF_TrainingVideos.aspx Med List Web application: http://medactionplan.com

Homework for January 19

• Chester City shared how they use IT to build reliability…

Be prepared on the start of the next call to share how you are using IT to build reliability.

What tools have you developed?

What alerts are you using?

What system are you working in to build these tools?

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Results of poll

IT platform for your hospital :

Cerner

Epic

Mckesson

Meditech

Other.

IHI Expedition

Effective Implementation of Heart Failure Core Processes

Hospital Guest Speaker

Sue Halter, RN, St. Luke’s

Hospital

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A NEW PERSPECTIVE: THE ST. LUKE’S STORY

THE ROAD TO ACHIEVEMENT

The “Journey” began by examining St. Luke’s Standards of Excellence

Sense of Ownership

Demonstrates personal commitment to St. Luke’s through quality job performance, a sense of responsibility for high achievement, professional appearance, awareness of current events throughout the hospital, and positive promotion of St. Luke’s.

Positive Attitude

Maintains a sense of understanding at all times while conveying energy and pride in all forms of communication: verbal, written, and non-verbal.

Compassion

Understands the feelings of another, and shows a sincere desire to help them. Involves listening carefully to them, talking to them about their feelings and concerns, meets special needs and uses appropriate non-verbal behavior.

Responsiveness

Accommodates the needs of others through the use of timely actions, clarification, apologies, considerations, and the offering of additional information.

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Our Adventure continued…………….. St. Luke’s joined the Institute for Health Care Improvement (IHI)

Innovation Project for Transitions to Home in February, 2006

Work concentrated on the Heart Failure patient to provide the “ideal” transition to home

Work in tandem with CMS indicators – Paradigm shift from focus on the

clinical needs a focus on the whole person and their social situation

over time

Goal: To Improve the reliability of the care patients receive and resultant outcomes

Team met (and continues to meet) monthly

Achieved The Joint Commission Advanced Disease Specific Certification in April, 2010

Transition to Home Team Members: Multifaceted!

• Heart Care Services Director • Unit Care Coordinators • Home Health Nursing

representatives • Cardiac Outcomes APNs • Respiratory/Critical Care staff

members • Performance Improvement

staff • Med-Surg Nursing Director • Social Services staff

• Pharmacy staff • Emergency Department staff • Unit managers • Cardiac Rehab staff • Pulmonary Rehab staff • Cardiology Clinic staff • Long-term care facility staff • Medical clinic staff • Medical Heart Failure Director • Family of Heart Failure patient

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Key Additions to the Team

Home Care representative

Family member of a HF patient

Long-Term Care representative

Physician Clinic representative

Paradigm shift

– Traditional focus on discharging patients facilitating transitions in care and a shift to handoffs (sender and receiver design the process together)

– Hospital problem Continuum issue

The “Atlas” for Patient ID

Patients identified via BNPs daily

Daily “huddles” within units (Charge, HF RN, Nurse, Care Coordinator)

Direct communication:

*HF RN with all unit Care Coordinators

*HF RN to HF ARNP

Diuretic list

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The Road Map: Core Measures

• HF 1: Discharge Instructions

• HF 2: LV Function

• HF3: ACE/ARB for LVSD

• HF4: Smoking Cessation

ACHIEVMENTS ON THE PATHWAY TO SUCCESS

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HF 1: Discharge Instructions

• Patient education done consistently *RN’s *HF RN *ARNP *Dietary (mandatory )

• Pre-printed computerized discharge instructions *Home *LTCF – patient education included • Computerized flow sheet charting

• Pink Sheet – final reminder

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Online Discharge Instructions

St Luke’s Hospital, Cedar Rapids, Iowa

Online Charting

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We use education so we don’t hit any bumps in the road! Utilizing “Teach Back” • Explain needed information to the patient or family caregiver. • You do not want your patient to view Teach Back as a test, but

rather of how well you explained the concept. You can place the responsibility on yourself.

• Can be both a diagnostic and teaching tool. • Use Teach Back daily in the hospital, at home, and during follow-up

phone calls. Teach Back Questions • What is the name of your water pill? • What weight gain should you report to your doctor? • What foods should you avoid? • What symptoms should you report to your doctor? Teach Back DVD – 2010 • Role modeling the teach back process • Patient reactions

Every trip

needs

souvenirs!

Heart Failure Magnet

Low sodium Eating plan

Example of a calendar

Take-home Tools

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Heart Failure Zones

EVERY DAY

Every day:

Weigh yourself in the morning before breakfast and write it down.

Take your medicine the way you should. Check for swelling in your feet, ankles, legs and stomach Eat low salt food Balance activity and rest periods

Which Heart Failure Zone are you today? Green, Yellow or Red

GREEN ZONE

All Clear This zone is your goal Your symptoms are under control You have:

No shortness of breath No weight gain more than 2 pounds (it may change 1 or 2 pounds some days) No swelling of your feet, ankles, legs or stomach No chest pain

YELLOW ZONE

Caution This zone is a warning Call your doctor’s office if:

You have a weight gain of 3 pounds in 1 day or a weight gain of 5 pounds or more in 1 week

More shortness of breath More swelling of your feet, ankles, legs, or stomach Feeling more tired. No energy Dry hacky cough

Dizziness Feeling uneasy, you know something is not right It is harder for you to breathe when lying down. You are needing to

sleep sitting up in a chair

RED ZONE

EMERGENCY Go to the emergency room or call 911 if you have any of the following:

Struggling to breathe. Unrelieved shortness of breath while sitting still

Have chest pain Have confusion or can’t think clearly

2/6/09

Heart Failure Zones

HF 2: Assessment of LV Function

• Dedicated HF RN

• HF ARNP • Pink sheet *Reminder to staff, physicians *Documentation compliance • Staff educated in heart failure/core measures *Orientation class *Inservices *Page before discharge test of change • Discharge HF order set *Evidence-based *EF must be documented

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HF 3: ACE/ARB for LVSD

• HF RN - patient review • • ARNP – patient rounds

• Pink sheet – documentation prior to discharge

• Daily huddles

• Bedside report

HF 4: Smoking Cessation

• ID on admission

• Automatic referral to Health Connections Coordinator *Daily list automatically generated from the previous day’s admission assessment/staff referral • Pink sheet

• Discharge Instructions

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Data consistently analyzed: Keep us on the right path

Databases: Review of patient charts concurrently

and after discharge *Heart Failure – follows all aspects of compliance, referrals from admission to home (review of patient chart concurrently and after discharge) *CMS *Get With the Guidelines *Length of stay *Readmissions *Aquapheresis – impact What we have learned has facilitated a change in direction at times, enabled “tests of change”, and taught us much!

0.96

1.00

0.93

1.00

0.50

0.60

0.70

0.80

0.90

1.00

HF DischargeInstructions

Left VentricularFunction

Assessment

ACEI & ARG forLVSD

Smoking Cessation

Heart Failure Measures 2nd Qtr 2011

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Does our guidance end when the patient goes home?

The answer is NO!

• Automatic referral for 3 – 5 day visit

• Appointment made for patient

• Outpatient Heart Failure Clinic: viewed as “resource”, not replacement for physicians

• 7-day follow-up phone call

• Home Health referrals, telemonitoring

Where we plan to go next… Future Actions

• Continue to keep vigilance to core measures

• Monitor All-Cause re-hospitalization rates to determine reason and actions to prevent

• Work on length of stay

• Work with Long-Term Care and Skilled Nursing care for improved transition

• Looking at the patient coming back to ED and going home from ED

• Incorporating consideration of “at risk sleep disorder population”

• Moving HF interventions to the COPD/Pneumonia population

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Homework for February 2 call

Suzetter Smookler, Registered Dietitian will be joining us to present on Dietary Restrictions for the HF Patient

Please come prepared to share:

• What are you currently using for the Sodium Restriction?

• What issues are you having as you try to reduce the Sodium restriction with the new recommendations, going as low as 1500mg?

Expedition Communications

• If you would like additional people to

receive session notifications please send

their email addresses to

improvementmap@ihi.org.

• We have set up a listserv for the

Expedition to enable you to share your

progress. To use the listserv, address an

email to HFExpedition@ls.ihi.org.

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Next Session

February 2, 2012, 12 – 1 PM ET

Guest Speaker, Suzzette Smookler, MS, RD,

CDN Stony Brook University Hospital

Dietary Implications For Patients with

Congestive Heart Failure (CHF)/Heart Failure

(HF)

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