11/29/2011
1
IHI Expedition:
Effective Implementation of Heart Failure Core
Processes
Peg Bradke, RN, MA, Faculty
Christine McMullan, MPA, Director
December 1, 2011
These presenters have nothing to disclose
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11/29/2011
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Today’s Agenda • Homework Discussion
─ Peg Bradke
• Improved Care for Patients
With Heart Failure at
Stonybrook University
Medical Center ─ Lisa Sokoloff
• Questions and Answers
• Increasing Reliability ─ Chris McMullan
• Homework for next session
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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.
11/29/2011
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Follow up discussion from Nov. 17 Call
• Concurrent vs Retrospective Chart Audits
• What has been the most efficient and effective process for your facility?
• How are you making the process work for you?
• If you could change how you are presently doing your audit”
What would it be?
What would it take to do?
Improved Care for Patients With Heart
Failure
“…to infinity and beyond”, Buzz Lightyear
But it feels like forever already!
11/29/2011
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HEART FAILURE NATIONAL HOSPITAL
INPATIENT QUALITY MEASURES
• HF-1 Discharge Instructions
• HF-2 Evaluation of LVS Function
• HF-3 ACEI or ARB for LVSD
• HF-4 Adult Smoking Cessation Advice/Counseling
HEART FAILURE- Other Considerations
•Readmission
•Length of Stay
•Mortality
11/29/2011
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HIDE and SEEK! Question: Where are the Heart Failure Patients?
Answer: Everywhere!
Currently…
• we have dedicated Heart
Failure RNs who screen
new admits to assist us in
identification (we still have
surprises)
Plan to…
• Utilize electronic record
more effectively (problem
lists; PowerPlans etc.)
• Link diagnosis and
PowerPlan to specific lists
(to notify HF team for
example) and required
activities
Discharge Instructions DESCRIPTION:
• HF patients discharged home with written
instructions or educational material given
to patient or caregiver at d/c or during the
hospital stay. The information must
address all of the following: activity level,
diet, discharge medications, follow-up
appointment, weight monitoring, and what
to do if symptoms worsen.
• Non-compliance with diet and medications
is an important reason for changes in
clinical status. Health care professionals
should ensure that patients and their
families understand their dietary
restrictions, activity recommendations,
prescribed medication regimen, and the
signs and symptoms of worsening heart
failure.
85.7%
92.4%
87.5%
93.4%
50%
60%
70%
80%
90%
100%
Q3 2010 Q4 2010 Q1 2011 Q2 2011
Compliance Target
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Currently… • All adults patients are given a generic
discharge instruction sheet on admit
(covers all required elements)
• Concurrent Review- Heart Failure
Service Nurse screens new admits to
identify heart failure patients and follow
up on completion of the
education/additional, documentation
• Zone Guide given at discharge to assist
with self management and early
recognition of impending exacerbation
They are missed when the diagnosis seems
secondary ; the standard work
strategies are not employed; hand
written D/C plan – error prone process
Plan to… • Electronic Depart Process to facilitate
medication reconciliation and discharge
instructions (roll- out imminent)
• Consider trialing Discharge Contract for
Cardiac patients
• Expand Clinical Integration role
– Enhance communication and early
f/u with community LIP or HF Clinic
– Smooth transitions for the patient
related to various needs including
medication management
– Early alternative intervention for
symptom management and
exacerbations
Discharge Instructions-
Discharge Planning
Starts on Admit:
This generic tool is given to
all adult patients on
Medicine units upon
admission, to start the
process of discharge
planning and satisfy the core
measure
11/29/2011
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Heart Failure
Specific Discharge
Education
DISTRIBUTION: White-Medical Record; Yellow-Patient
What is Congestive Heart Failure (CHF)? CHF means that your heart muscle is weak and can no longer pump blood with enough force to all parts of your body. When this happens, fluid backs up in the lungs and other parts of the body. CHF can make it more difficult for you to do normal daily activities that may have been easy for you in the past. Good control of your disease can improve the quality of your life Please follow the following guidelines: MEDICATIONS
♥ Take your medicine as prescribed by your physician(s). It may take many months to feel the effect of these medications.
♥ Do not take more than the prescribed dose. ♥ If you miss a dose, take it as soon as you remember, but do not take two doses at the same
time. ♥ Take your medications at the same time every day. ♥ If you have several physicians, make sure they all know what medications you are taking.
DIET ♥ Eat a well balanced diet of three meals per day; restricted to 2 grams of sodium per day. ♥ Eat at regular times every day. ♥ Follow fat, salt and other possible restrictions if your physician has told you to do so.
WEIGHT ♥ Check you weight every day on the same scale with minimal clothing and write it
down on a calendar. This is because one the symptoms of worsening CHF is fluid
accumulation, which would cause a gain in weight.
ACTIVITY
♥ Some regular activity is very helpful for your heart. ♥ Do not undertake an exercise program without first speaking to your physician. ♥ Walking is an excellent routine form of exercise, but recognize your limitations. ♥ Take frequent rest periods and pace yourself to conserve energy. ♥ Plan your activities, so you avoid temperature extremes. ♥ If you are too short of breath talk, you need to slow your pace or stop. If you remain short of
breath after slowing down, you need to call your physician.
PREVENTION
♥ Get a Pneumonia vaccine shot at least once in your life. ♥ Get a FLU vaccine shot every year in the Fall unless directed otherwise by your physician. ♥ Smoking Cessation advice and counseling have been provided if you smoked cigarettes
within the last twelve months. Discontinue smoking to maintain or improve heart function.
CALL YOUR PHYSICIAN IF: ♥ You experience: weight gain of more than 3 pounds in a day (or 5 pounds in a week),
increase in cough, swelling in your body, shortness of breath, or chest pain.
♥ You need to increase the number of pillows to sleep at night. ♥ You are running low on medication.
Sign below to acknowledge that I have received and reviewed these instructions with a nurse.
Patient Signature: _________________________ Date:___________________
Nurse Signature:___________________________ ID#___________ Date:_______ Time:_______
CONGESTIVE HEART FAILURE (CHF) DISCHARGE SHEET
ME2C033 (4/05)
Heart Failure Zone Guide
– An educational tool created to
help patients & families
recognize symptoms of HF
and seek treatment before
emergency care is needed
– Goal is to improve symptom
management and recognition
to decrease CHF
exacerbations and
readmissions
– Spanish version to be printed
on reverse side
– Efforts to roll out to SNFs also
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Evaluation of Left Ventricular
Systolic (LVS) Function DESCRIPTION:
• HF patients with
documentation in the hospital
record that LVS function was
evaluated before arrival, during
hospitalization, or is planned
for after d/c.
• Rationale: Appropriate
selection of medications to
reduce morbidity and mortality
in HF requires the identification
of patients with impaired LVS
function.
100% 100% 98.3% 100%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Q3 2010 Q4 2010 Q1 2011 Q2 2011
Compliance Target
ACEI or ARB for Left Ventricular
Systolic Dysfunction (LVSD) DESRIPTION:
• HF patients with LVSD prescribed an
ACEI or ARB at hospital d/c.
• For purposes of this measure, LVSD is
defined as chart documentation of a left
ventricular ejection fraction (LVEF) less
than 40% or a narrative description of
left ventricular systolic (LVS) function
consistent with moderate or severe
systolic dysfunction.
• Rationale: ACEI therapy reduces
mortality and morbidity in patients with
HF and LVSD and are effective in a wide
range of patients.
94.7%
90.5% 90.0% 90.0%
50%
60%
70%
80%
90%
100%
Q3 2010 Q4 2010 Q1 2011 Q2 2011
Compliance Target
11/29/2011
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LVF Assessment and ACE I/ARB
Use/Documentation Currently…
• Powerplans (Heart Failure
Admit; Heart Failure as a
Secondary Diagnosis; order
sentences built into Medicine
Admit Powerplan)
• Concurrent review by Heart
Failure Service (1 MD in-patient
and out-patient; 1 RN, M-F)
• Paper rounding tools (DGS)
Plan to…
• Enhanced opportunities for
documentation during
hospitalization
• In-patient Heart Failure Service
Team (2 MDs and 2 RNs) sees
all patients with a primary or
secondary diagnosis of HF (as
per their screen)
• Electronic Depart Process
They are missed because of
documentation issues primarily; lack of discreet fields; lack of hard stops at D/C
Currently
bedside
rounding tools
cue the team to
consider core
measures and
offer another
opportunity for
documentation
MEDICINE GOALS /PLAN OF CARE
Hospital Admission:_____________ Unit Admission:_____________ Planned date of discharge:_____________
Current Diagnosis: _____________________________________________________________________________ Isolation? No Yes: Code: ______ Organism(s):____________ Surveillance cultures sent Advance Directives Discussed ? Yes No Patient has Advanced Directive with copy in chart Code Status: Full code DNR DNI Code status renewed on: _____________________
Medication Reconciliation complete: Yes No SYSTEM STATUS/PROBLEMS
Date/Time: ____________________
PLAN & DAILY GOALS/OUTCOMES:
Date/Time: ____________________
Prophylaxis:
DVT: SCDs Heparin Lovenox NA
GI: Yes No Contraindicated NA
Cont. Current Management
Diagnostics planned: __________________________
Monitor parameter: __________________________
Change therapy: __________________________
IMPORTANT: Evaluate Patient’s ability to switch to PO medications as soon as possible.
Fluids/medications: IV abx IV Fluids:__________________ Antibiotic day ____ of ____
Switched to PO medications IV fluids: Continue Discontinue
Change to : ______
Neurological: A&O X 3 Confused H/O seizure
Maintain patient’s orientation/safety Seizure precautions
Respiratory: Lungs clear Trach Adventitious: Describe:_________________ Requires O2: Sats: ________ Home O2 On Nebulizer
Maintain O2 sat of _________ Wean off oxygen Head of bed elevated Suction as needed Continue Nebulizer
Cardiovascular/Hemodynamic: Chest pain: Yes No
Requires telemetry
Elevated/low: BP: ____, HR: ____, RR:____,
Temp:____, TMax:_____
>0.15 Troponin % EF: ___________
Re-new telemetry Cardiology consult EKG Transfuse HF d/c Instruction sheet signed and in chart For LVSD, prescribe ACE/ARD or document
contraindication for both Anticoagulant at d/c for HF patient with atrial
fibrillation. GI/GU/Nutrition: Feeding: self assist tube feeding NPO Swallowing difficulty
Pain/difficulty on urination Urinary catheter Constipation Diarrhea Abdominal pain Date of last BM: _____________
Speech and swallow consult
Discontinue catheter
Stool for CDiff
Order stool softener
Resume diet Nutrition Consult
Skin: Skin intact Pressure ulcer: Stage: _______ Location: _______
ET consult Continue dressings as ordered New dressing regimen: see chart for orders
SIDE 1 OF 2 cm (8/10/07)
11/29/2011
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Electronic
Solutions?
Adult Smoking Cessation Advice/Counseling
DESCRIPTION:
• HF patients with a history of smoking
cigarettes, who are given smoking
cessation advice or counseling during
hospital stay. For purposes of this
measure, a smoker is defined as
someone who has smoked cigarettes
anytime during the year prior to hospital
arrival.
• Rationale: Smoking cessation reduces
mortality and morbidity in all
populations. Patients who receive even
brief smoking-cessation advice from
their care providers are more likely to
quit.
100% 100% 100% 100%
0%
25%
50%
75%
100%
Q3 2010 Q4 2010 Q1 2011 Q2 2011
Compliance Target
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Staff Education is Ongoing
Summary / Next Steps:
• Actively driving the use of the electronic PowerPlan for primary and
secondary Heart Failure (electronic alert in place)
• Concurrent screening of all new admits for a primary or secondary
diagnosis of HF or an admitting diagnosis or profile suggestive of such
(review of B-type natriuretic peptide results, ejection fraction %
reports, chief complaint on admit etc.)
• Real time reminders/education to the staff to consider/document a
specific element of care; utilize hard stops
• Implement electronic depart process
– drive medication reconciliation process
– provide opportunities to staff at discharge for documentation and
patient education related to core measures
11/29/2011
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Summary/Next Steps:
• Annual nursing and physician education regarding heart failure and
core measures
• Distribute pocket guides describing heart failure care and core
measures.
• Unit and physician specific data regarding HF core measure
compliance reported to leadership monthly and compliance data is
posted on the units Quality boards.
• Globalization of discharge instructions
• Implement Clinical Integration to smooth transitions (early f/u;
medication reconciliation and poly pharmacy; enhanced
communication; improved support services post d/c)
Summary/Next Steps:
• Develop/Implement ED /Observation Unit HF Protocol
• Work with area SNFs to identify s/s earlier and work
collaboratively
• VAD program
• Concurrent Coding / Clinical Documentation
11/29/2011
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Composite Score
DESCRIPTION:
• The total number of
patients eligible to
receive all of the core
measure indicators
divided by the actual
number of patients
that received them all.
87.0%
91.0%
87.0%
92.8%
50%
60%
70%
80%
90%
100%
Q3 2010 Q4 2010 Q1 2011 Q2 2011
Compliance Target
Heart Failure 30-Day Mortality and 30-Day
Readmit Rates Q3 2007 - Q2 2010
8.80%
11.30%
0%
4%
8%
12%
Our Hospital's RiskStandardized Mortality
Rate
US National Rate
24.60% 24.80%
0%
10%
20%
30%
Our Hospital's RiskStandardized Readmission
Rate
US National Rate
11/29/2011
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Follow-up discussion after Stony Brook
Stony Brook shared their bedside
rounding tool.
• What trigger tools have you used to
assure compliance to core measures?
• How are you educating staff on the
core measures patients?
IHI Expedition
Effective Implementation of Heart Failure Core
Processes
Increasing Reliability
Christine McMullan, MPA, Director
11/29/2011
16
Survey Responses
Director of Quality, Nurse Practitioner, Registered Nurse, Chart
Abstractor and Clinical Nurse Specialist
Survey Question: How are you
identifying patients?
• Admitting diagnosis
• Concurrent review
• H&P medical diagnosis history
• Elevated BNP levels
• EMR triggers
11/29/2011
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Survey Question: 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
33
Increasing Reliability
• Provide prompts on admission for standard order sets for patients with congestive heart failure (CHF).
• Implement standard, diagnosis-based order sets, with an “opt out” (with documented explanation of why the standard is not being followed).
• Create a standard process to obtain prior LVS assessments before ordering a new LVS assessment.
• Use alerts and reminders, electronic or paper, that the patient has CHF and requires automatic implementation of standard orders.
• Introduce a concurrent review process to identify patients who have not received all the evidence-based care.
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Homework for Next call
Have a discussion with coding.
• What has been you experience with
your identification of HF patients as it
relates to the final diagnosis code
assigned?
• What action have you taken to assure
findings are similar?
Expedition Communications
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receive session notifications please send
their email addresses to
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Expedition to enable you to share your
progress. To use the listserv, address an
email to [email protected].