ihi expedition: effective implementation of heart failure core … heart fai… · interventional...

11/15/2011

1

IHI Expedition:

Effective Implementation of Heart Failure Core

Processes

Peg Bradke, RN, MA, Faculty

Christine McMullan, MPA, Director

November 17, 2011

These presenters have nothing to disclose

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What is your goal for participating in this

Expedition?

4

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Join Passport to:

• Get unlimited access to Expeditions, two- to four-month,

interactive, web-based programs designed to help front-line teams

make rapid improvements.

• Train your middle managers to effectively lead quality

improvement initiatives.

• Enhance your strategic planning with customized whole systems

data and selected benchmarking information.

. . . and much, much more for $5,000 per year! •

• Visit www.IHI.org/passport for details.

• To enroll, call 617-301-4800 or email [email protected].

What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for

some specific purpose

2. the group of persons engaged in such an

activity

3. promptness or speed in accomplishing

something

http://www.ihi.org/passport

mailto:[email protected]

11/15/2011

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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.

Where are you joining from?

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Ground Rules

• We learn from one another – ―All teach,

all learn‖

• Why reinvent the wheel? - Steal

shamelessly

• This is a transparent learning

environment

• All ideas/feedback are welcome and

encouraged!

Schedule of Calls

• November 17 12:00 – 1:30 PM ET

Introduction, Objectives, Expedition Overview

• December 1, 2011, 12 – 1 PM ET

Importance of LVS assessment in the reliable recognition of HF

• December 15, 2011, 12 – 1 PM ET

Offering adult smoking cessation advice and counseling

• January 5, 2012, 12 – 1 PM ET

Benefits of providing ACE/ARBs at discharge for HF patients

• January 19, 2012, 12 – 1 PM ET

Anticoagulant at discharge for chronic atrial fibrillation

• February 2, 2012, 12 – 1 PM ET

Discharge instructions and dietary considerations

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Today’s Agenda

• Expedition objectives and

your survey responses

• Medical management for

heart failure

• IHI’s Model for Improvement

• Overview for increasing

reliability with heart failure

core processes

• Homework for next session

11

Expedition Objectives

• To provide hospitals with highly effective ideas

and practices in improving reliability in the

treatment of heart failure.

The expedition will focus on key elements of care to

ensure patients with heart failure have less severe

symptoms, better quality of life, and fewer

readmissions to the hospital.

• Conduct left ventricular systolic (LVS) assessment

• Provide adult smoking cessation advice and counseling

• Provide ACE inhibitor or angiotensin receptor blockers (ARB) at

discharge

• Provide anticoagulant at discharge for chronic atrial fibrillation

• Establish discharge instructions

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Survey Responses

Director of Quality, Nurse Practitioner, Registered Nurse, Chart

Abstractor and Clinical Nurse Specialist

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Survey Responses

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Goal for participation

• Learn from others

• Collaborate with others in improving

quality

• To better understand core measure

processes

• Improve heart failure care

• Prevent readmission

How are you identifying patients?

• Admitting diagnosis

• Concurrent review

• H&P medical diagnosis history

• Elevated BNP levels

• EMR triggers

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What are your barriers to reliability?

• Physician and nurse lack of

understanding of core measures

• MD and RN collaboration on discharge

instructions/medication reconciliation

• Electronic health record – both pro and

con

• Inability to identify HF patients on

admission

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Last Quarter Composite Score

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William E. Lawson, M.D., FACCP, FACC, FSCAI

Dr. William Lawson graduated from Rutgers Medical

School in 1977. Dr. Lawson has been at SUNY, Stony

Brook since 1980, where he is currently Professor of

Medicine in the Division of Cardiology. At Stony Brook he

has acted as Chief of Cardiology, Director of

Echocardiography, Non-Invasive, Invasive, and Preventive

Cardiology. He is currently Director of Cardiac Outcomes

Research and Preventive Cardiology. Dr. Lawson is a

practicing interventional cardiologist and Director of the

Interventional Cardiology fellowship program at Stony

Brook. Dr. Lawson is ABIM certified in Internal Medicine,

Cardiovascular Disease, Interventional Cardiology,

Advanced Heart Failure & Transplant Cardiology and is a

Fellow of the ACC, ACCP, SCAI, ACA. He has broad

expertise and interest in the field of cardiovascular

disease and is actively involved in the teaching and

mentoring of physicians and allied health care

professionals at SUNY, Stony Brook.

CONGESTIVE HEART FAILURE

William E. Lawson, M.D., FACCP, FACC, FSCAI

Stony Brook Hospital

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Heart Failure:

A Growing Burden

• Prevalence is increasing:

– Aging populations, HBP, DM, MI survivors.

– Overall rate is 3-20/1,000.

– Rate over age 65 is 30-130/1,000.

• One –year mortality rates are 35-45% in newly diagnosed cases.

• Heart failure is the most frequent cause of hospitalization over age 65.

Symptoms

• Fatigue, easy tiring

• Dyspnea, Dyspnea on exertion, Paroxysmal

nocturnal dyspnea

• Edema

• Persistent cough/ wheezing

• Palpitations, presyncope

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Cardiac cachexia

Hepatomegaly

JVD/ HJR

Ascites

Congestive Heart

Failure

New Classification of Heart Failure

Stage Patient Description

A High risk of developing

heart failure (HF)

• Hypertension

• CAD

• Diabetes mellitus

• Family history of cardiomyopathy

B Asymptomatic LVD • Previous MI

• LV systolic dysfunction

• Asymptomatic valvular disease

C Symptomatic LVD • Known structural heart disease

• Shortness of breath and fatigue

• Reduced exercise tolerance

D Refractory

end-stage HF

• Marked symptoms at rest despite maximal

medical therapy (eg, those who are

recurrently hospitalized or cannot be

safely discharged from the hospital

without specialized interventions)

Hunt SA et al. J Am Coll Cardiol. 2001;38:2101-2113.

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Lindenfeld J, et al. HFSA 2010 Comprehensive

Heart Failure Guideline. J Card Fail 2010;16:e1-e194.

HF Risk Factor Treatment Goals

Risk Factor Goal

Hypertension Generally < 130/80

Diabetes See ADA guidelines1

Hyperlipidemia See NCEP guidelines2

Inactivity 20-30 min. aerobic 3-5 x wk.

Obesity Weight reduction < 30 BMI

Alcohol Men ≤ 2 drinks/day, women ≤ 1

Smoking Cessation

Dietary Sodium Maximum 2-3 g/day 1Diabetes Care 2006; 29: S4-S42

2JAMA 2001; 285:2486-97

Adapted from:

Treating Hypertension to Prevent HF

Aggressive blood

pressure control: Aggressive BP control

in patients with prior MI:

Decreases

risk of

new HF

by ~ 80%

Decreases

risk of

new HF

by ~ 50%

56% in DM2

Lancet 1991;338:1281-5 (STOP-Hypertension

JAMA 1997;278:212-6 (SHEP)

UKPDS Group. UKPDS 38. BMJ 1998;317:703-713

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After a 2 year visit to the US, Michelangelo’s David is returning to Italy

Sponsored

by



Prevention—ACEI and Beta Blockers

ACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with:

Coronary artery disease

Peripheral vascular disease

Stroke

Diabetes and another major risk factor Strength of Evidence = A

ACE inhibitors and beta blockers are recommended for all patients with prior MI. Strength of Evidence = A

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Management of Patients with Known

Atherosclerotic Disease But No HF

Treatment with ACE

inhibitors decreases

the risk of CV death,

MI, stroke, or cardiac

arrest.

NEJM 2000;342:145-53 (HOPE)

Lancet 2003;362:782-8 (EUROPA)

02468

10121416

0 1 2 3 4

Years

% MI,Stroke,

CV Death

0

3

6

9

12

15

0 1 2 3 4 5

Years

% MI, CV Death, Cardiac Arrest

Placebo

Ramipril

Placebo

Perindopril

20% rel. risk red. p = .0003

22% rel. risk red. p < .001

HOPE

EUROPA

CAD; Leading

Cause of Heart

Failure

• Post MI survivors

– Magnitude of initial infarct, cumulative

damage, adverse remodeling all play roles

• Chronic ischemia and LV dysfunction

– Prolonged ischemia causes hibernation,

stunning

– Shorter periods of ischemia result in reversible

myocardial dysfunction

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Angioplasty

Pre PCI Post PCI

Cardiorenal Hemodynamic Neurohumoral

Digitalis and Inotropes and Modification of

diurtics improve vasodilators activation of

cardiac and improve LV adrenergic,

renal function performance RAAS systems

The Evolving Model

of Heart Failure

Treatment

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Treatment of Post-MI Patients with

Asymptomatic LV Dysfunction (LVEF ≤ 40%)

SAVE Study

All-cause mortality ↓19%

CV mortality ↓21%

HF development ↓37%

Recurrent MI ↓25%

0

0.1

0.2

0.3

0 0.5 1 1.5 2 2.5 3 3.5 4

Placebo

Captopril

Years

Mortality

Rate

19% rel. risk reduction

p = 0.019

Pfeffer et al. NEJM 1992;327:669-77

Added Value of BB Post-MI

Beta blocker (carvedilol) benefit post-MI with LVEF

≤ 40%, receiving usual therapy [revascularization,

anticoagulants, ASA, and ACEI]. Capricorn trial

All-cause mortality reduced (HR = 0.077; p = 0.03)

Cardiovascular mortality reduced

(HR = 0.75; p = .024)

Recurrent non-fatal MIs reduced (HR =.59; p = .014)

Dargie HJ. Lancet 2001;357:1385-90

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Causes of Dyspnea



Therapy: ACE Inhibitors

ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%. Strength of Evidence = A

ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C

ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.

Post MI Strength of Evidence = B

Non Post-MI Strength of Evidence = C

Adapted from:

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ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HF

SOLVD Prevention

(Asymptomatic LVD)

20% death or HF hosp.

29% death or new HF

CONSENSUS

(Severe Heart Failure)

40% mortality at 6 mos.

31% mortality at 1 year

27% mortality at end of

study

No difference in incidence

of sudden cardiac death

SOLVD Investigators. N Engl J Med 1992;327:685-91

SOLVD Investigators. N Engl J Med 1991;325:293-302

CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35

(Chronic Heart Failure)

SOLVD Treatment

16% mortality



Therapy: Beta Blockers

Beta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%.

Strength of Evidence = A

Beta blockers are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%.

Post MI Strength of Evidence = B

Non Post-MI Strength of Evidence = C

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IMPACT-HF Primary End Point: Patients Receiving Beta Blocker at 60 Days

91%

73%

0%

25%

50%

75%

100%

Pati

en

ts

P <.0001

Carvedilol

Predischarge Initiation

(n=185)

Physician Discretion

Postdischarge Initiation*

(n=178)

18% Improvement

Gattis WA et al. JACC 2004;43:1534-41



Therapy: Angiotensin Receptor

Blockers

ARBs are recommended for routine

administration to symptomatic and

asymptomatic patients with an

LVEF ≤ 40% who are intolerant to

ACE inhibitors for reasons other than

hyperkalemia or renal insufficiency.


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ARBS in Patients Not Taking ACE Inhibitors:

Val-HeFT & CHARM-Alternative

50

60

70

80

90

100

0 3 6 9 12 15 18 21 24 27

Val-HeFT

Valsartan

Placebo

p = 0.017

Months

Su

rviv

al %

0

10

20

30

40

50

0 9 18 27 36C

V D

eath

or

HF

Ho

sp

%

Placebo

Candesartan

CHARM-Alternative

HR 0.77, p = 0.0004

Months

Maggioni AP et al. JACC 2002;40:1422-4

Granger CB et al. Lancet 2003;362:772-6



Therapy: Aldosterone Antagonists

An aldosterone antagonist is recommended for

patients on standard therapy, including diuretics,

who have:

NYHA class III or IV HF from reduced LVEF (≤ 35%)

One should be considered in patients post-MI

with clinical HF or diabetes and an LVEF < 40%

who are on standard therapy, including an ACE

inhibitor (or ARB) and a beta blocker.

Adapted from:


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Aldosterone Antagonists in HF

0 .40

0 .50

0 .60

0 .70

0 .80

0 .90

1 .00

0 3 6 9 12 15 18 21 24 27 30 33 36

RALES (Advanced HF)

0 .40

0 .50

0 .60

0 .70

0 .80

0 .90

1 .00

0 3 6 9 12 15 18 21 24 27 30 33 36

EPHESUS (Post-MI)

Spironolactone

Placebo

Months

RR = 0.70

P < 0.001

Eplerenone

Placebo

RR = 0.85

P < 0.008

Pitt B. N Engl J Med 1999;341:709-17

Pitt B. N Engl J Med 2003;348:1309-21

Pro

ba

bil

ity o

f S

urv

ival



Therapy: Hydralazine and Oral

Nitrates

A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with HF and reduced LVEF:

NYHA III or IV HF Strength of Evidence = A

NYHA II HF Strength of Evidence = B

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A-HeFT All-Cause Mortality

85

90

95

100

0 100 200 300 400 500 600

Survival %

Days Since Baseline Visit

43% Decrease in Mortality

Fixed Dose ISDN/HDZN

Placebo

P = 0.01

Taylor AL et al. N Engl J Med 2004;351:2049-57



Therapy: Diuretics

Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by:

Congestive symptoms

Signs of elevated filling pressures Strength of Evidence = A

Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF. Strength of Evidence = B

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Stage A Stage B Stage C Stage D

Treat HBP All Stage A All Stage A All Stage A,

Stop smoking measures measures B,C measures

Treat lipids ACEI in post ACEI LVAD

Exercise MI, reduced Diuretics Ht Transplant

No ETOH LVEF BB Continuous

No Drugs BB in post MI, Digitalis IV inotropes

ACEI in DM, reduced LVEF Spironolactone

HBP, Vascular in Class III,IV

Disease

Treatment by Heart

Failure Stage



Device Therapy: Prophylactic ICD Placement

Prophylactic ICD placement should be considered in patients

with an LVEF ≤35% and mild to moderate HF symptoms:

Ischemic etiology Strength of Evidence = A

Non-ischemic etiology Strength of Evidence = B

In patients who are undergoing implantation of a biventricular pacing device, use of a device that provides defibrillation should be considered. Strength of Evidence = B

Decisions should be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions, ideally after 3-6 mos. of optimal medical therapy. Strength of Evidence = C

Adapted from:

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MADIT II: Prophylactic ICD in

Ischemic LVD (LVEF 30%)

3 65 (.69) 170 (.78) 329 (.90) 490 Conventional

9 110 (.78) 274 (.84) 503 (.91) 742 Defibrillator

Number at Risk

0 1 2 3

.7

.8

.9

1.0

Pro

ba

bil

ity o

f S

urv

iva

l

Conventional

Therapy

Defibrillator

Year

.6

0 4

Moss AJ et al. N Engl J Med 2002;346:877-83

Two leads allow

pacing of the right

atrium and ventricle.

The third lead is

advanced through the

coronary sinus into a

venous branch along

the lateral wall of the

left ventricle,

allowing early

activation of the left

ventricle.

Resynchronization

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Device Therapy:

Biventricular Pacing

Biventricular pacing therapy is recommended for

patients with all of the following:

Sinus rhythm

A widened QRS interval (≥120 ms)

Severe LV systolic dysfunction (LVEF < 35%)

Persistent, moderate-to-severe HF (NYHA III)

despite optimal medical therapy.


CRT Improves Quality of Life and

NYHA Functional Class Average Change in Score

(MLWHF)

-20

-15

-10

-5

0

MIR

AC

LE

MU

STIC

SR

CO

NTA

K C

D

MIR

AC

LE IC

D

Control CRT

* * * *

*P<.05

NYHA: Proportion Improving

by 1 or More Class

0

20

40

60

80

MIRACLE CONTAK

CD

MIRACLE

ICD

Control CRT

**

*

(%)

Abraham WT et al. Circulation 2003;108:2596-603

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CRT in Patients with Advanced HF and a

Prolonged QRS Interval: COMPANION

Bristow MR et al. N Engl J Med 2004;350:2140-50

Primary End Point: All-Cause Mortality

Death or Hospitalization Due to HF

Risk of all-cause mortality reduced by 19%

in group with CRT and ICD (p =.014)

Risk of death or hospitalization from HF

reduced by 34% in ICD group and by 40% in

ICD-CRT group (p < .001)

Effect of CRT Without an ICD on

All-Cause Mortality: CARE-HF

5

71

192

321

365

404

Medical Therapy

8

89

213

351

376

409

CRT

Number at risk

0 500 1,000 1,500

25

50

75

100

% E

ven

t-F

ree S

urv

ival

Medical

Therapy

CRT

Days

0

HR = 0.64 (95% CI = .48-.85)

p = .0019

Cleland JG et al. N Engl J Med 2005;352:1539-49

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Treatment Options: Acute Decompensated HF

Fluid and sodium restriction

Diuretics, especially loop diuretics

Ultrafiltration/renal replacement therapy (in selected patients only)

Parenteral vasodilators (nitroglycerin, nitroprusside, nesiritide)

Inotropes (milrinone or dobutamine)

Clinical Presentation of

Acute Decompensated

Heart Failure

Clincal Evaluation of

Acute Decompensated

Heart Failure

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Impact of Education on Compliance

Nonadherence rate when patients . . .

Recall MD advice Don’t recall advice

Medications 8.7% 66.7%

Diet 23.6% 55.8%

Activity 76.4% 84.5%

Smoking 60.0% 90.4%

Alcohol 60.0% 81.8%

Kravitz et al. Arch Int Med 1993;153:1869-78

Evidence-Based Treatment Across the

Continuum of Systolic LVD and HF

Control Volume Improve Clinical Outcomes

Diuretics

Digoxin

-Blocker ACEI

or ARB

Aldosterone

Antagonist

or ARB

Treat Residual Symptoms

±CRT

& ICD

Hydralazine/Isosorbide dinitrate

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? The Future: Angiogenesis/ Myogenesis

via Cell Transplants

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Questions?

Raise your hand

Use the Chat

61

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that

will result in improvement?

Model for Improvement

Act Plan

Study Do

Aim of Improvement

Measurement of

Improvement

Developing a Change

Testing a Change

Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W.,

Norman, C. L., & Provost, L. P. The Improvement Guide:

A Practical Approach to Enhancing Organizational

Performance. San Francisco, CA: Jossey-Bass, 1996.

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Plan • Compose aim

•Pose questions/predictions

•Create action plan to carry

out cycle (who, what, when,

where)

•Plan for data collection

Do Study

Act

• Carry out the test and

collect data

•Document what occurred

•Begin analysis of data

• Complete data analysis

•Compare to predictions

•Summarize learning

• Decide changes to make

•Arrange next cycle

Principles & Guidelines for Testing

• A test of change should answer a specific

question

• A test of change requires a theory and prediction

• Test on a small scale

• Collect data over time

• Build knowledge sequentially with multiple PDSA

cycles for each change idea

• Include a wide range of conditions in the

sequence of tests

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Repeated Use of the PDSA Cycle

Hunches

Theories

Ideas

Changes That

Result in

Improvement

A P

S D

A P

S D

Very Small

Scale Test

Follow-up

Tests

Wide-Scale Tests

of Change

Implementation of

Change

Sequential building of knowledge under a wide range of conditions Spread

Aim: Implement Rapid Response Team on non-

ICU unit

Improved

Communication

A P

S D

A P

S D

Cycle 1: ICU nurse responds to rapid response team calls on one unit,

one shift for one day

Cycle 2: Repeat cycle 1 for three days

Cycle 3: Have Respiratory Therapist attend

rapid response calls with ICU Nurse

Cycle 4: Expand coverage of RRT on unit

to one unit for one shift for five days

Cycle 5: Have Nurse Practitioner

respond to calls in addition to RT and

RN

Cycle 6: Expand rounds to

one unit for one shift seven

days a week

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Questions?

Raise your hand

Use the Chat

67

IHI Heart Failure Expedition

IHI Expedition 2011

Peg M. Bradke, RN, MA

St. Luke’s Hospital, Cedar Rapids, Iowa

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Heart Failure Core Measures

• HF1 – Discharge Instructions

• HF 2 – Evaluation of LVS Function

• HF 3 – AEI or ARB for LVSD

• HF 4 – Adult Smoking Cessation

Advice/Counseling

69

What are the drivers?

• Doing the Right thing with Evidenced

Based Care for our Patients

• Meeting requirements for Valued Based

Purchasing

• Marketing –Consumer Access to Hospital

Compare.gov

• Reducing Our Potential Avoidable

Readmissions

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Doing the Right thing

• The right care for every patient, every time

• Is any defect acceptable

─ To us as a health care system?

─ To you as a health care professional?

─ To anyone expecting the care we would want our loved ones to receive?

─ Which would you be okay with your loved not getting?

Legislative Requirements for

VBP

Multiple Requirements • Legislation requires that the FY 2013 Hospital VBP

program apply to payments for discharge occurring on or

after Oct. 2012

• Hospital VBP measures must be included on Hospital

Compare website

• Under proposal, measures could be added to Hospital

VBP if measures have been displayed on Hospital

Compare for one year

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HQA Recent Report for HF

10%of all Hospital National Performance

Submitting equal

to or better than

100%

HF 1-discharge 100% 90%

HF 2- LV function 100% 98%

HF 3- ACE/ARB 100% 95%

HF 4- Smoking Cessation 100% 97%

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―The Billion Dollar U-Turn‖

• 17.6% of all Medicare admissions are readmissions within 30 days

─ Accounting for $15 B in spending

• Not all re-hospitalizations are avoidable, but many are

─ 13.3% of all Medicare admissions; 76% potentially avoidable

─ Accounts for $12B in Medicare spending

─ Heart Failure, Pneumonia, COPD, Acute MI lead the medical conditions

─ CABG, PTCA, other vascular procedures lead the surgical conditions

─ Disparities exist along racial and ―burden of illness‖ lines

• There is wide intra-state and inter-state variation

─ Medicare 30-day readmission rate varies 13-24% by state

Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008

MedPAC Report to Congress, Promoting Greater Efficiency in Medicare. June 2007

Commonwealth Fund State Scorecard on Health System Performance. June 2007

• Provide technical assistance to front-line teams of providers working to

improve the transition out of the hospital and into the next care setting

• Actively engage hospitals and their community partners in co-designing processes to

improve transitions

• Provide coaching by content experts and facilitate collaborative learning with the goals

of creating exemplary cross continuum models in each state and identifying high-

leverage changes in each care setting

• Develop quality improvement expertise and content experts to mentor others

• Create and support state-based, multi-stakeholder initiatives to

concurrently examine and address the systemic barriers to improving

care transitions, care coordination over time.

• State leadership, steering committees, key allies, aligning initiatives

• Technical assistance to ―staff‖ challenges in framing the issue, designing strategy,

scanning for developments in best practice/policy

• Specific focus areas: understanding the financial impact of success, aligning payment

to support high leverage interventions, developing state rehospitalization data reports

STAAR Initiative: Two Concurrent Strategies

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Transition from Hospital to Home

• Enhanced Assessment

• Teaching and Learning

• Real-time Handover Communications

• Follow-up Care Arranged

Post-Acute Care Activated

• MD Follow-up Visit

• Home Health Care (as needed)

• Social Services (as needed)

• Skilled Nursing Facility Services

Alternative or Supplemental Care for High-Risk

Patients *

• Hospice/Palliative Care

• Transitional Care Models

• Intensive Care Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare)

or

IHI’s Roadmap for Improving

Transitions and Reducing Avoidable

Rehospitalizations

* Additional Costs

for these Services

Improved

Transitions

and Coordination

of Care

Reduction in

Avoidable

Rehospitalizations

Patient and Family Engagement

Cross-Continuum Team Collaboration

Evidence-based Care in All Clinical Settings

Health Information Exchange and Shared Care Plans

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I. Perform Enhanced Admission Assessment of Post-Hospital

Needs

A. Involve the patient, family caregivers and community providers as full partners in

completing a needs assessment of the patient home going needs

B. Reconcile medications

C. C. Identify the patient’s initial risk of readmission

D. Create a customized discharge plan based on the assessment.

II. Provide Effective Teaching and Facilitate Enhanced Learning

A. Involve all learner in patient education

B. Redesign patient education process

C. Redesign patient teaching print materials

D. Use Teachback regularly throughout the hospital stay

III. Ensure Post-Hospital Care Follow-Up

A. Reassess the patient’s medical and social risk for readmission.

B. Prior to discharge:

• Schedule timely follow-up care and

• Initiate clinical and social services summarized from the assessment of post-hospital

needs.

IV. Provide Real-Time Handover Communication

A. Give patient and family members a patient-friendly post-hospital care plan which includes a

clear medication list.

B. Provide customized, real-time critical information to next clinical care provider(s).

C. For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care

provider(s) to discuss the patient’s status and plan of care.

Creating an Ideal Transition Home

Analysis of Results-to-Date

• Reducing readmissions is dependent on highly functional

cross continuum teams and a focus on the patient’s journey

over time

• Improving transitions in care requires co-design of

transitional care processes among ―senders and receivers‖

• Providing intensive care management services for targeted

high risk patients is critical

• Reliable implementation of changes in pilot units or pilot

populations require 18 to 24 months

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Other Resources • BOOST

─Toolkit –Medication Reconciliation, Treatment

plan, discharge summary communication

• Hospital to Home H2H (ACC/IHI)

─Virtual Learning Community and H2H website

• Project RED

─Reconciling the discharge plan with national

guidelines and critical pathways when

relevant – CMS discharge list

Building Reliability

• Need Reliability of the Evidenced Based

Core measures to build on the continuum

of care after discharge

• Core Measures work in tandem with

Readmission Effort

• First step identifying the Core Measure

Patients

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Who identifies the HF

Core Measure Patients

• Frontline Staff vs. dedicated individual

Frontline staff needs to understand the measures

and the context of the work

• All departments must take ownership to

manage the process

• Role of Nursing Unit Leadership and

Senior Leadership

How do you identify the HF

Core Measure Patient?

BNP: ß-type Natriuretic Peptide

─ Hormone released into the blood in response to

increased heart pressure or overload

─ Circulating BNP has an inverse relationship to degree

of cardiac dysfunction (the higher the BNP, the lower

the ejection-fraction and the higher New York Heart

Association Level)

IV Lasix/Diuretic Report

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Follow Up in EMR

Verify the patient has HF through chart

review and daily rounds

• Patient has symptoms of HF

• Physician notes that patient exhibits

symptoms of HF

• Note if patient has previous history of HF

Is Your Approach ―Real Time‖

• Reviewing Concurrently with concurrent

chart abstraction ─ Literature reports the results of core measures

improved significantly. These methods prove to be

efficient and cost effective as les time was required

when compared to retrospective chart review and

more current data were available to anaylze and act

upon.

─ Advantages include just in time one to one education

of staff, optimizing evidenced based patient care

opportunities and documentation, and responding to

staff questions.

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Documentation

• Documentation is a key driver

─Accurate and complete to meet measure

definitions

─ Impact on coding

─Patient Safety

─Maximize Reimbursements

Results Retrospective of Chart

Review Six patients did not have proper discharge

instructions:

• Two patients had cancer – documentation of chemo-induced heart failure

• One patient with admitting diagnosis of allergic reaction

• One patient ICD implant

• Remaining two were heart failure diagnoses that were missed

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Core Measure Discharge

Tools or Checklists

• Are you using a Discharge Checklist to assess compliance during the hospitalization and then at the time of discharge with national guidelines for care of HF patient

Please share you tools/checklist or processes over the time of this expeditions.

HF – 1 Discharge Instruction

Numerator: Heart Failure patients with documentation that

they or their caregivers were given written discharge

instructions or other educational material addressing all of

the following:

1. Activity level

2. Diet

3. Discharge Medications

4. Follow up appointment

5. Weight Monitoring

6. What to do if symptoms worsen

Denominator: Heart failure patients discharged home

90

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HF Discharge Instructions

• Use pre-printed heart failure discharge instructions on the following patients: newly diagnosed or history of heart failure patients that we are currently treating for HF; history of ischemic cardiomyopathy or LVEF <40; patients currently hospitalized to have Bi-V or ICD implant who have a history of CHF or LVEF <40%.

PATIENT EDUCATION

• YOU ARE THE PATIENT’S LIFELINE FOR INFORMATION!

• Give in small doses

• Use their terms

• Be empathetic but emphatic!

• Ask specific questions to determine their knowledge level (how much sodium/how much weight to report/when to weigh, etc.)

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Medication Reconciliation

♥ Home Medication List

♥ Hospital Medication List

♥ Discharge Instructions

♥ Physician’s Discharge Summary

ALL MUST MATCH EXACTLY!!

Many errors around lack of medication

reconciliation at discharge

Medication Reconciliation cont.

Includes -

♥ All prescribed medications

♥ All over the counter medications

♥ All PRN medications

♥ Medication name, dosage and route

Same rules apply for Long term or skilled care facilities

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Medication Reconciliation cont. • What is your check process for your providers

and staff?

Do you do a discharge time out?

Do you do a double check by two independent reviewers?

Is a Pharmacist involved?

• How do you assure all medications are addressed?

• How do you assure required discharged medications are addressed?

HF 2- Evaluation of LVS Function

• Numerator: Heart failure patients with

documentation in the hospital record that

LVS function was evaluated before arrival,

during hospitalization, or is planned for

after discharge.

• Denominator: Heart failure patients

96

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EF

• Amount of blood pumped out of the heart

with each contraction

• Normal = 50 – 70%

• Abnormal in CMS world = <40%

HF 3 – ACEI or ARB for LVSD

• Numerator: Heart Failure patients who are

prescribed an ACEI or ARB at hospital

discharge

• Denominator: Heart failure patients with

LVSD

98

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Contraindications

CMS updates the measures twice a year – the contraindications frequently are areas that are changed. Don’t worry about specific contraindications. Just encourage the Providers to document any contraindications (i.e. CHF & Acute Beta Blockers or Coumadin and Acute ASA)

HF 4 – Adult Smoking

Cessation Advice/Counseling

• Numerator: Heart failure patients

(cigarette smokers) who receive smoking

cessation advice or counseling during the

hospital stay

• Denominator: Heart failure patients with a

history of smoking cigarettes any time

during the year prior to hospital arrival

100

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SMOKING

ALL PATIENTS regardless of diagnosis, need documentation of smoking education (cessation education, stay quit or second hand smoke exposure).

♥ If unable to give this to the patient, it can be given to the family.

♥ If unable to give education at the time the initial nursing

history/assessment is completed and documented, smoking

education cessation should be documented when the patient is able

to receive the information

HF BEST PRACTICE

• LVEF Assessment – preferably within the past two years

• Smoking cessation education for current smokers and those who have smoked in the past 12 months

• ACE Inhibitor or ARB prescribed at discharge for patients with LVEF of less than 40% (if ACE or ARB is not used the physician needs to document the reason for both)

• Preprinted CHF Discharge Instructions Utilized – to cover key CHF information including weight monitoring, medications, diet, what to do if symptoms worsen, activity and follow-up

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Make your process sustainable

over time

• Continually manage the process using the

PDSA cycle

• Keep your eye focused on enhancing the

process rather than blaming someone or

some group for failure

• Key to work: culture change,

communication and teamwork Let’s use this expedition to share our best practices and

learn from each other.

Homework for Next Call

• What has been your experience in

concurrent data abstraction for core

measures as opposed to retrospective?

─Do you have results that demonstrate

improved efficiency and/or results for a given

method?

─Be prepared to discuss your findings for

advantages/or disadvantages for the method

you are utilizing.

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Expedition Communications

• If you would like additional people to

receive session notifications please send

their email addresses to

[email protected].

• We have set up a listserv for the

Expedition to enable you to share your

progress. To use the listserv, address an

email to [email protected].

Next Session

December 1, 2011, 12 – 1 PM ET

Importance of LVS assessment in the

reliable recognition of HF

106



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